VSM Secure

Canadian Vascular Surgery Minimum

Unofficial 2008 Review Notes
University of Ottawa
Anton Sara!ov" M#
U!dated $une %" 200%
C u r e o c c a s i o n a l l y " r e l i e v e o f t e n " c o n s o l e a l w a y s & A & 'ar( )*)+,)*%0
-at follows" is a collection of notes gleaned from multitude of scra!s" scri..les" summaries of te/ts
0!rimarily Ruterford and Moore1" and in,training written e/ams in Ottawa& Originally 2 started writing
tings down in !re!aration for my Canadian and American Vascular 3oards& 2 did not find a unified edita.le
collection of review notes anywere" ence 2 decided to do tis !ro4ect&
5ese notes are 6AR from .eing com!reensive& Also" .eing a uge fan of 7Made Ridiculously Sim!le8
series and 7-atever for 2diot9s8 fracise 0more .y necessity" rater tan .y coice1" 2 may ave
oversim!lified tings a .it to ma:e it easier to understand and memori;e& So consider information critically&
5is is a com!osite .ody of wor: s!anning several years of study notes written .y te Canadian Vascular
surgery fellows and wic were !assed on to te ne/t generation& 2 edited tese and added a few of
im!ressions < .iases of mine own& My study !artners Wesam Abuznadah, MD" a fellow at U of Calgary
and Hao Ming Wu, fellow at U of 3ritis Colum.ia" were instrumental wit several revisions of te draft&
Our tan:s go to te generations of scri..lers and note ta:ers" to te 73ig R8" as well as to our staff
surgeons& -e formed a google study grou!" and conduted almost daily conference meetings over S:y!e
wic was el!ful&
5is is not a su.stitute for reading Ruterford or doing actual oral e/ams& 2 :now of several successful
vascular surgeons wo never did read Ruterford from cover to cover .ut tey are 4ust !lain .rilliant and full
of uni.ited genius& So unless you are all tat" read your 7.ig R8& 2 did&
5is is a wor: in !rogress& =ou can9t >uote wat9s written ere as te statements contained erein may all .e
!ronounced .las!emous * years down te roadJ ?owever" tis is loosely .ased on wat9s e/!ected to
:now on te written !art of te Canadian Vascular 3oard& 6eel free to email me at
antonsara!ov@yaoo&com wit constructive ctiticism etc&
5o navigate" !ress C5RA and clic: on te item in te Content&
Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD
age 2
Contents
'RBO'C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))
)&Clinical ris: inde/esC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))
2&?ow does 'ersantine scan wor:D &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2
E&Role of CA# screening !reo!D &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E
F&CAR' studyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E
*&Courage studyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E
G&'O2SB studyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F
+&Res!iratory assessment and fitness for toracotomyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F
8&Bagle criteriaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F
%&Modified Aee criteria &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*
)0&-at are MB5SD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*
))&Arterial MR2 studiesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G
?BMO#=NAM2CS AN# #O''ABRC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G
)2&?emodynamic !rinci!lesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G
)E& Non,invasive testing overviewC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%
)F&#o!!ler wave formsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%
)G&Resting A32 H advantages and disadavantagesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22
)+& Stress testing and A32C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F
)8& B/tremity arterial du!le/ and stenosisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2G
)%&Venous graft follow u!C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 28
20&-y does steal after fem,fem or a/,.ifem occur rarelyD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 28
2)&Carotid ultrasound H -asington" NASCB5 and BCS5 criteria &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 28
22&Normal Carotid and Verte.ral flow velocitiesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2%
2E&Consensus !anel on US criteria on stenosisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& E)
2F&Oter useful velocities measurement for carotids &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& EE
2*&6re>uency of Surveylence of :nown stenosis &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& EF
2G&5ranscranial #o!!ler &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& EF
2+& Renal artery US &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& E*
28&Mesenteric du!le/ &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& E+
2%& US and BVAR &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& E8
E0&Ultrasound of 5rans!lantC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& E%
E)&Ultrasound and cronic venous insufficiency &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F0
E2& Caracteristics of venous flowC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F)
EE& Ultrasound and #ialysis access &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F2
A5?BROSCABROS2S < R2SI 6AC5ORS9 5JC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& FE
EF&'ysiologic role of endotelium C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& FE
E*&6actors im!ortant for aterosclerotic !la>ue develo!mentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& FE
EG&Role of macro!ages in aterosclerosis" list macro!age secreted K6C &&&&&&&&&&&&&&&&&&&& FF
E+&-at a!!ens in aterosclerosisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& FF
E8&Stages in aterosclerosis and ty!es of !la>uesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& FF
E%&Name different mediators secreted .y endoteliumC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F*
F0& Bndotelial !rogenitor cellsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F*
F)&Mecanism of action of Nitric o/ide" or Bndotelial #erived Rela/ing 6actorC &&&&&&& F*
F2&Bffects of smo:ingC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F*
age E
FE&Mecanism of action of Angiotensin 22C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& FG
FF& ACB2 effectsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F+
F*& -at are te effects of statinsD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F8
FG& $u!iter trial" 200%C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F8
F+&-at mecanical factors can in4ure endoteliumD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F%
F8&Ste!s in intimal y!er!lasia develo!mentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F%
F%& ?ow can intimal y!er!lasia .e !reventedLtreatedD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *0
*0&?ow can R6 for aterosclerosis .e modifiedC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *0
*)&5arget for li!idsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *)
*2&'A# and ris: reductionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *)
*E&Conservative measures of treatment of claudicationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *F
*F&## of claudicationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& **
**&Ris: factors and mar:er of increased ris: for 'V#C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& **
*G&-at en;ymatic deficiency is found in y!eromocysteinemiaD &&&&&&&&&&&&&&&&&&&&&&&&&&&&& **
S=M'A5?BC5OM= &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *G
*+&?ow does sym!atectomy wor:D &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *G
*8&2ndications for Aower e/tremity sym!atectomyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *G
*%&Aum.ar sym!atectomyC outcome M &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *+
G0&U!!er e/tremity sym!atectomyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *8
VASCUA252S &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *8
G)&Raynaud9sC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *8
G2&Connective tissue disordersC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G)
GE& #iffirential diagnosis of !ositive ANAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G2
GF&VasculitisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G2
G*&5y!es of 5a:ayasu ArteritisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G2
GG&Kiant cell arteritisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& GF
G+&3ecet disease diagnosisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G*
G8&O5?BR Mid < small vessel vasculitisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& GG
G%& Small vessel arteritisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G+
+0& Small vessel !atology leading to digital iscemiaC ## &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G+
+)&Arteritis associated wit aneurysm formationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G+
-B2R# < -ON#BR6UA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G+
+2&3uerger9s disease diagnostic criteriaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G+
+E&Angiogra!ic features of 3uerger9s diseaseC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G8
+F&Uncommon causes of aneurysms &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G%
+*&5y!es of collagenC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +0
+G& 6eatures of !seudo/antoma elasticumD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +0
++&'atology of radiation vasculitisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +0
+8&Clinical syndromes associated wit cystic medial necrosisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +0
+%&Visceral S!lancnic Artery aneursymsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +)
80&Classification of s!lenic a& aneurysmsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +)
8)&2ndications and treatment for s!lenic artery aneurysm re!airC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +)
82&?e!atic a& aneurysmC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +2
8E&SMA" celiac" gastroe!i!loic aneurysmC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +2
8F& Renal a& aneurysmC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +E
8*&Com!le/ regional !ain syndrome C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +E
age F
8G&5y!es of 6M#C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +F
8+& Most common arteries affected wit 6M#N &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +*
88& 'ortal y!ertension and .leedC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +*
8%&2ndication to treat vasc malfomationsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +*
%0& ?am.urg classification of vascular malformationsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +G
%)&Ili!!el,5renaunayC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +G
%2& Sclerotera!yC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ++
%E& Vascular tumorsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ++
%F&Congenital defects and sym!tomsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ++
%*& 'ersistent sciatic arteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ++
%G& A..erant Rt& Su.clavian arteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +8
%+& -at is re>uired to ave a normal erectionD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +8
%8& Brectile disorderC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +%
BM3OA2SM" 5?ROM3OS2S < A2M3 2SC?BM2A 2N KBNBRAA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 80
%%& Causes of arterial occlusion in generalC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 80
)00& Most common sources of em.olismC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8)
)0)& Most common sites of em.olisationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8)
)02& Ateroem.olic Renal falureC i&e& !arencimal causesM &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 82
)0E& Causes of arterial trom.osisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8E
)0F& Btiology of !ost o! acute Aeg iscemia !ost AAA re!airC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8E
)0*& 2nfrainguinal graft trom.osisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8F
)0G&2scemia < re!erfusion effects on organsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8*
COAKUAA52ON < AN52COAKUAA52ON &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8G
)0+& Summari;e coagulation cascadeC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8G
)08& ?ow does #e/tran F0 wor:D &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 88
)0%&-arfarinC mecanism of action and com!licationsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8%
))0&Contraindications to warfarin tera!yC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8%
)))&-at drugs affect warfarinC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %)
80& ?e!arin vs AM-?C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %)
))2&'rotamine mecanism of actionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %2
))E&#irect 5rom.in ini.itorsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %2
#2SOR#BRS O6 COAKUAA52ON &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %2
))F& ?25C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %2
))*& ?y!ercoagula.le stateC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %E
))G& Anti!os!oli!id anti.odiesC ,AAC" ACA and SABC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %F
))+& Resistance to activated factor VC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %F
))8& Causes of mesenteric trom.osisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %F
8G& Common ac>uired causes of .leeding and teir treatmentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %*
5?ROM3OA=S2S &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %G
))%&5y!es of trom.olyticsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %G
)20& Contraindications to trom.olysisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %+
)2)&5rom.olysis studies summaryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %+
)22&2ntrao!erative trom.olysisC ow toM &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %%
#V5 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )00
)2E&#iagnostic criteria for #V5C C#6M &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )00
)2F& R6 and outcomes for #V5C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )00
age *
)2*&#,dimer in diagosis of #V5C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0F
)2G&-ays to treat #V5C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0F
)2+&2ndications for 2VC filterC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0G
)28&Com!lications of 2VC filterC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0G
)2%&Migratory !le.itisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0+
)E0&Bffort trom.osisC classify &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0+
)E)&5reatment o!tions for !rimary a/illary vein trom.osisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0+
)E2&2liofemoral Venous trom.osisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0%
C?RON2C VBNOUS 2NSU662C2BNC= &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0%
)EE&Venous flow caracteristicsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0%
)EF&#eterminants of venous flowC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))0
)E*&Cause of Cronic venous insufficiencyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))0
)EG&-ave forms of venous !letysmogra!y in severe S6$ reflu/C &&&&&&&&&&&&&&&&&&&&&&&&&&&&& )))
)E+&Venous disease assessmentC CBA' classification &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))E
)E8&A!!roac to venous ulcersC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))F
)E%&Name veins ligated during sa!enous vein stri!!ingC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))%
)F0&-y does vein stri!!ing surgery failC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))%
)F)&Venous claudicationC cause &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))%
)F2&Cronic 2VCLiliacLdee! vein o.structionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )20
)FE&SVC o.structionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )20
)FF&-y .y!asses for venous re!air are !rone to failureD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2)
)F*&Aist AB !erforatorsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2)
)FG&2ndications for !erforator ligationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )22
#2AA=S2S ACCBSS &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2E
)F+&'rinci!les of AV6 creationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2E
)F8&Access o!tions in Central Vein OcclusionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2F
)F%&Com!lications of AV6 creationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2F
)*0& 5reatment of AV6 stealC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2F
A=M'?B#BMA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2*
)*)&Aym! !ysiologyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2*
)*2&Classify lym!edemaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2*
)*E&Aong term com!lications of Aym!edemaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2+
)*F&5reatment of lym!edemaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2+
U''BR A2M3 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )28
)**&Kenearl causes of u!!er lim. iscemiaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )28
)*G&Sym!toms < signs of 5OSC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2%
)*+&A!!roac to !t wit 5OS &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2%
)*8&Com!lications of )st ri. resectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E)
)*%&2ndications for surgery of a su.clavian a& aneurysmC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E)
)G0&Vi.ration wite fingerC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E)
)G)&?y!otenar ?ammer SyndromeC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E)
)G2&Occu!ational acro,osteolysisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E2
)GE&Atletic in4uriesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E2
Aower A2M3 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E2
)GF&#ifferential diagnosis of .ilateral lower lim. swellingC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E2
)G*&A!!roac to distal !eroneal a& &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )EE
age G
)GG&6ate of a claudicantC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )EF
)G+&CA2 criteriaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E8
)G8&Natural / of !ts wit CA2C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E%
)G%&5ASC classification for iliac and S6A lesionsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E%
)+0&3AS2A studyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F0
)+)&Vein advantages over !rosteticC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F)
)+2&O!tions for .y!ass graft material in descending order of !referenceC &&&&&&&&&&&&&&&&&& )F)
)+E&Syntetic grafts H caracteristicsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F2
)+F&Adverse effects of Vein arvestC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )FE
)+*&B/!ected !atency of vascular grafts < !roceduresC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )FE
)+G&Com!lications after infrainguinal revasculari;ationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )FG
)++&Kraft surveilanceC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F8
)+8&2liac '5A H ris:s of !rocedureC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F%
)+%&'rimary and secondary !atencyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F%
)80&5ests for evaluation of te donor iliac artery !rior to fem,femC &&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*)
)8)&'o!liteal aneurysmC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*)
)82&A!!roaces to !o! aneurysm re!airC advantages and disadvantages &&&&&&&&&&&&&&&&&&&&& )*2
)8E&Koals of !eri!eral aneurysm treatmentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*E
)8F&Nerves encountered in !o!liteal a& e/!osureC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*E
)8*&Cystic adventitial diseaseC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*E
)8G& Angio findings in adventitial cystic disease &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*F
)8+&Causes of !o!liteal a& occlusion in order of fre>uency& &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*F
)88&5y!es of !o!liteal entra!mentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*F
)8%&Causes of early lim. edema after a femoro,ti.ial KSV .y!ass &&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*G
)%0&Causes of com!artment syndromeC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*G
)%)&Calf com!artmentsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*8
)%2&Acute lim. iscemia classificationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*8
)%E&Am!utation level and .onesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*8
)%F&#efine different ty!es of am!utationsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*8
)%*&5ests to use to select level of am!utationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G0
)%G&Com!lication of .elow :nee am!utationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G0
)%+&Com!are arterial" venous and neuro!atic ulcers& &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G)
)%8&'ato!ysiologic mecanisms in dia.etic footC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G2
CARO52#S &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )GF
)%%&3rances of B/ternal Carotid arteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )GF
200&2nternal carotid artery anatomyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )GF
20)& B/ternal carotid to internal carotid a& collateralsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )GF
202&Clinical !resentations of cere.ral syndromesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G*
20E&Visual syndromesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G+
20F&2ndication for carotid du!le/C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G+
20*&2CA and CCA #o!!ler !rofile &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G8
20G&Carotid du!le/ artery stenosis criteriaC -asington Criteria &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+0
20+&Consensus !anel on US criteria on carotid stenosisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+0
208&Oter useful velocities measurement for carotids &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+)
20%&6re>uency of Surveillance of :nown asym!tomatic stenosis &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+2
2)0&Mecanisms of stro:eC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+2
age +
2))&Aa. and investigations for 52AC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+E
2)2&Recurrent CVA after 52A or CVAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+G
2)E&5iming of CBA wit res!ect to CVA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )++
2)F&Contraindications to CBA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )++
2)*&Com!lications of CBAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+8
2)G&Conduct of CBAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+8
2)+&2ndication for BCA endarterectomyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+%
2)8&#ifficult access to 2CAC ig 2CA" difficult 2CA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+%
2)%&Nerves encountered during CBA H &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+%
220&Nascet findingsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )80
22)&Asym!tomatic Carotid artery stenosis and ACAS findingsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )8)
222&Carotid !atcing H advantages and disadvantagesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )8F
22E&Recurrent stenosis after CBAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )8G
22F& Carotid sunt com!licationsD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )8+
22*&CBA and CA3K H decision ma:ing in vasc surgeryC !& 8G &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )8+
22G&CAS trialsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )88
228&A 2CA occlusion& -at do doD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%2
22%& Verte.ral insufficiencyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%2
2E0&Revasculari;ation of verte.ral arteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%E
2E)&#escri.e steal" outline treatmentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%E
2E2&3rances of su.clavian arteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%F
2EE&3rances of a/illary arteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%F
2EF&6eatures of s!ontaneous carotid dissectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%*
2E*&Carotid 6M#C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%G
2EG&B/tracranial Carotic artery aneurymsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%G
2E+&Carotid .ody tumorC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%+
2E8& 2nnervation of carotid .odyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%8
MBSBN5BR2C 2SC?BM2AC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%8
2E%&-at are te non,aterosclerotic causes of cronic mesenteric iscemiaD &&&&&&&&&&&& )%8
2F0&Causes of intestinal iscemiaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%%
2F)&#o!!ler findings in mesenteric iscemiaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%%
2F2&Common variations of Common ?e!atic ArteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 200
2FE&5reatment of mesenteric iscemiaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 200
2FF&#ifferences .etween acute and cronic mesenteric iscemiaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20)
2F*&?ow to determine intrao!erative .owel via.ilityD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20)
RBNOVASCUAAR #2SBASB &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20)
2FG&#ifferentiate Renovascular ?y!ertension from oter causes of ?5ND &&&&&&&&&&&&&&&&& 20)
2F+&Mecanism of renal ?5NC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 202
2F8&Ca!to!ril ne!rogramC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20E
2F%&Renal a& du!le/C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20F
2*0&Surgical causes of y!ertensionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20F
2*)&Causes of RV ?5N" RV y!ertensionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20F
2*2&RV ?5N treatment and resultsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20*
2*E&2ndications of concomitant aortic and renal reconstructionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20+
2*F&Renal artery aneurysm re!air indicationsC RA aneu &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 208
2**&A!!roac to renal arteriesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20%
age 8
2*G&B/,vivo reconstructionC indications &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20%
2*+&2ndication for re!air of renal artery in traumaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)0
AAA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)0
2*8&AAA e!idemiology and causeC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)0
2*%&'rinci!al matri/ fi.ers in aorta" wat canges are seen in AAAD &&&&&&&&&&&&&&&&&&&&&&&&&& 2))
2G0&Ris: factors for AAA #B5BC52ONC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2))
2G)&Natural istory AAA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)2
2G2&Relevant C5 findings in !ts wit AAA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)2
2GE&R6 for AAA ru!ture &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)E
2GF&Ru!tured AAA managementC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)E
2G*&2nflammatory AAAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)F
2GG&2ndications for retro!eritoneal R' re!airC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)F
2G+&Anatomic criteria for BVARC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)F
2G8&5y!es of endolea:sC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)F
2G%&S!ecific com!lications of BVAR ,endovascular AAA re!air &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)*
2+0&6ollow u! after BVAR& Bndolea: treatmentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)*
2+)&#ream" BVAR ) and BVAR 2 findings &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)+
2+2& ?arvard Medicare Registry study &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)+
2+E& 2ndications for angio in !t wit AAAC angio for AAA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)%
5?ORACOA3#OM2NAA ANBUR=SM &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)%
2+F&5oracoa.dominal aneurysm 05A1 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)%
2+*&#ecision ma:ing in assessing !t wit 5AAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22)
2+G&Strategy for renal !rotection in 5AAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 222
2++&-y is te s!inal cord at ris: during re!air of 5AAD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 222
2+8&S!inal cord !rotection metods during 5A re!airC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22E
2+%&3leeding during 5AA" causeC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22*
280&-en sould we NO5 cover SCA in toracic endograftingD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22*
AOR52C #2SSBC52ONC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22G
28)&Aortic #issectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22G
AOR5O2A2AC OCCAUS2VB #2SBASB 0A2O#1 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22%
282&A!!roac to !t wit A2O#C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22%
28E&2ndication for Bnd to Bnd vs Bnd to Side for A36C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E0
28F&2ndication for A/illo,.i,femoral KraftC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E)
28*&5y!es of endarterectomy& #iscuss aortic endarterectomy &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E2
28G&Causes of AV communications involving aorta and its9 .rancesC &&&&&&&&&&&&&&&&&&&&&&&& 2EF
28+&'otential !ysiologic and anatomic conse>uences of a large AV6C &&&&&&&&&&&&&&&&&&&&&& 2EF
288&Aortocaval fistulaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2EF
COM'A2CA52ONS &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E*
28%&Cardiac and Res!iratory Com!lications of vascular surgeryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E*
2%0&2scemic neuro!atyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2EG
2%)&Com!lications of aortic surgeryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E+
2%2&Strategy to minimi;e renal damage during aortic clam!ingD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E8
2%E&Clinical caracteristics" ris: and diagnosis of iscemic colitisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E8
2%F&Colon iscemia avoidance after AAA re!airC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E%
2%*&?ow to !revent se/ual disfuntion wit aortic surgeryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F0
2%G&?ow to im!rove !elvic circulationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F0
age %
2%+&2ncidence of com!lications wit different ty!e of accessC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F0
2%8&'seudoaneurysm formationC causes &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F0
2%%&'ost Angio !seudoaneurysmC wyD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F)
E00&2ntraartearial drug in4ection H mecanism of in4ury < t/ &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F)
E0)&-at increases contrast ne!ro!atyD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F2
E02&Advantages of low osmolarity contrast to com!ared to igD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FE
E0E&Kado!entate #imeglumine a:a CO2M &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FE
E0F&Com!lications of .lood transfusionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FE
E0*&#ifference .etween seroma and lym!oceleD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FE
2N6BC5B# KRA65 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FF
E0G&Native vascular vessel infectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FF
E0+&C5 findings for infected !rostetic graftC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FG
E08&Ris: 6actors !redis!osing to graft infectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FG
E0%&'revention of graft infectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F+
E)0&2nvestigation of !t wit draining R groin wound !ost A36 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F8
E))&2nfected A36 graftC #raining sinus in groin !ost A36C a!!roac H &&&&&&&&&&&&&&&&&&&&&& 2F8
E)2&Classification of graft infectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F%
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F%
E)E&C5 findings of aortoenteric fistulaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*0
E)F&Selection of !ts for infected graft !reservationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*0
E)*&Selection of infected graft for insitu re!lacementC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*0
E)G& Results of aortic graft infection treatmentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*)
E)+& Aorto,enteric fistulaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*)
5RAUMAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*F
E)8&Carotid a& in4ury and neurologic deficit& -en to fi/D &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*F
E)%&5reatment of .lunt carotid in4uryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*F
E20&Cest vascular traumaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2**
E2)&Radiogra!ic clues to !otential .lunt aortic in4uryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*+
E22&Most common .lunt vascular toracic in4uriesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*+
E2E&Conservative treatment of toracic aortic in4uriesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*+
E2F& A.dominal vascular traumaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*+
E2*&B/tremity trauma notesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2G0
E2G&5raumatic AV6C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2G)
age )0
PREOP:
1. Clinical risk indexes:
o Koldman Cardiac ris: inde/
o Modified Aee
o #ets:y CR2
o Bagle CR2
o American ?eart Association guidelinesC
o Varia.les consideredC
age" recent M2" C?6" BCK a.n" aortic stenosis" emergency OR"
!oor general ealt" intra,a.doLtoraci" aortic surgery&
o O.4ective measuresC
BCK H if a.normal" E fold increase in !erio! com!lications" if
normal H not !redictiveM&
B/ercise BCK , less a!!lica.le in vascular surgeryC
su.o!timalLsu.ma/imal effort due to disa.ility" ig false,negative&
?olter H good !redictor if a.normal& )0O can9t inter!ret
meaningfully" ence false !ositivesC due to BCK canges not due to
CA#&
Stress,5alliumC under conditions of near ma/imal coronary flow
0di!yridamoleLadenosine induced1" eterogenous !erfusion areas are
identified&
Reasona.le test to order if !t is deemed intermediate ris: .y
clinical assessment& Kood alternative H do.utamine BC?O&
NUCABAR MB#2C2NB 5BS5SC
'erfusion studiesC
o Myoview H test of myocardial !erfusion only"
o 'B5 H more so!isticated form of myoviewC
tells were !erfusion is a!!ening
distinguises scar vs via.le vs necrotic myocardium
3lood !ool studyC
o MUKA H myocardial !erfusion AN# ventricular function&
age ))
'rovides te most accurate assessment of AV6
StressC
o Add !ersantine" do.utamine" adenosine&
2. How does Persantine scan work?
o 3aseline tallium nucleotide scan is done
o #i!yridamole is administered
o #i!yridamole dilates coronary circulation
o As a result" flow to NON,stenotic vessels is increased
o Stenotic vessel distri.ution sows delayed early u!ta:e
o On re!eat imaging" tallium gets into te remaining myocardium
0inter!reted as redistri.ution or delayed u!ta:e1 OR does not 0inter!reted as
scar1
o AsideC di!yridamole 0or !ersantine1 is a !os!odiesterase ini.itor H will
increase cAM'" decrease CaPP" and decrease !latelet aggregationM
5ASC 22
*0O of !ts wit 'V# ave CA#
2*O of !ts wit 'V# ave Carotid disease
)0O of !ts wit Carotid disease ave 'V#
E0O wit Carotid disease ave CA#
20O of !ts wit CA# ave Carotid disease
)0O of !ts wit CA# ave 'V#
age )2
3. Role of CAD screening preop?
role undefinedM
o CA# is !revalent" .ut rates of M2 are fairly low
Aorta 2O" CBA )O" infrainguinal FO 0Ruterford1
o Cardiac screening detects !rimarly ?# sig stenosis
Acute coronary syndrome does not occur wit most ?#
significant stenosis Most autors state ris: stratification
is im!recise at .est
o Aong term .enefits of CA# revasculari;ation 0if it is !erformed1
may not a!!ly for !ts wit 'V#M
5ere are no validated invasive or non,invasive metods to 2# !la>ues
tat are vulnera.le to disru!tion
?ence !reo! o!timi;ation sould aim at !la>ue sta.ili;ation
2t is agreed tere is role for 33 and statins !reo!
-ell done negative !rovocative test ave ig N'V
o 'ositive test" owever" does not ave ig ''V
4. CARP study:
o Coronary Artery Revasculari;ation 'ro!yla/is 0CAR'1 trial
o ?y!otesisC
among sta.le !atients wit CA# tat is amena.le to CA3K or 'C2"
coronary artery revasculari;ation !rior to elective surgery im!roves
long,term survival&
o multicenter" randomi;ed" controlled" coo!erative trial
)8 Veterans Affairs Medical Centers&
'atients sceduled for aortic and infrainguinal vascular o!eration eligi.le
o Screen,Q angio,Qrandomi;ed to revasc vs no revasc
o Screened *800" randomi;ed *00
o ResultC
revasculari;ation !rocedure delaysL!revents te vascular o!eration
does not im!rove eiter sort, or long,term survival&
5. Courage study:
'redictive value of 'OS252VB !reo!erative !armacologic nuclear !erfusion
scanning is 'OOR 0*,20O1
o N'V is e/cellent 0%8,)00O1
200G" Study settingC
'atients wit
o cronic angina !ectoris"
o sta.le !ost,myocardial infarction 0M21 !atients
o asym!tomatic !atients wit o.4ective evidence of myocardial iscemia
age )E
i&e& !ositive non,invasive tesingLscanning
o 228+ !ts randomi;ed to eiter aggressive med tera!y vs 'C2 !lus tera!y
o At * years" same num.er of !ts is angina free
o No difference noted&
o Role of 'C2 !reo! sould .e >uestionedM
6. POIS study:
Multi!le SMAAA studies sowed .eneficial effect of 3eta .loc:ers on CV
mortality in !erio!erative setting 0e&g&#BCRBASB trial1
5is was tested in a +000 !t RC5 in !ts undergoing non,cardiac surgery
Meto!rolol vs !lace.o
Overall tere was reduction in M2 .ut tere was increase in stro:e and overall
mortality in Meto!rolol grou!
for every )000 !atients treated" meto!rolol would !revent )* M2s .ut tere would
.e an e/cess of eigt deats and five severe disa.ling stro:es
effects attri.uted to ig dose 33 tat com!ound !erio!erative soc:
recommendation is to use lower dose" start 33 early to allow accommodation of
dose" and avoid e/tended release !re!aration&
tt!CLLcme&medsca!e&comLviewarticleL*+F*2G
7. Respiratory assess!ent and fitness for t"oracoto!y:
'65C if 6BV) Q G0O or #ACO Q G0O , will tolerate u! to !neumonectomy
6BV) and #ACO R G0O
o Suantitative lung scan
2f !redicted !ost o! 6BV) and #ACO Q F0O
May !rocede to surgery
2f ''V 6BV) and #ACO R F0O
'erform /ercise testingC
o 2f VO2 ma/ Q 20 mlL:gLmin
'rocede to surgery
)*,20 ml H GGO ris: of com!licatios
Q 20 ml H )0O ris: of com!lications
o 2f VO2 ma/ R )* mlL:gLmin
3eware of )00O ris: of com!lications
8. agle criteria:
o Age Q +0
o #ia.etes
o Angina Q class E
o C?6
o 'rev M2
age )F
o BCK canges
o Aortic stenosis
o Ventricular arrytmia
9. #odified $ee criteria
'redicts ris: of ma4or cardiac com!licationsC
o #M 0insulin de!endent1
o CVAL52A
o AnginaLM2L !revious CA3KL'5A
o C?6
o Renal insufficiency Q )80 0Q 21
o ?ig ris: !rocedure
A.do" toracic" aortic" visceral
o cardiac ris: inde/ as .een validated in num.er of studies
ris: of ma4or vasc com!lications is e>ual to te num.er of R6
s>uared
Num.er of ris: factor Ri:s of ma4or cardiac com!lications
0 0&*O
) )&EO
2 FO
E %O
10.%"at are #&S?
1MET
T Can you ta:e care of yourselfD
T Bat" dress" or use te toiletD
T -al: indoors around te ouseD
T -al: a .loc: or two on level ground at 2 to E m! or E&2 to F&8 :m !er D
4METs
T #o ligt wor: around te ouse li:e dusting or wasing disesD
T Clim. a fligt of stairs or wal: u! a illD
T -al: on level ground at F m! or G&F :m !er D
T Run a sort distanceD
T #o eavy wor: around te ouse li:e scru..ing floors or lifting or moving eavy
furnitureD
T 'artici!ate in moderate recreational activities li:e golf" .owling" dancing" dou.les
tennis" or trowing a .ase.all or foot.allD
>10METs
age )*
T 'artici!ate in strenuous s!orts li:e swimming" singles tennis" foot.all" .as:et.all" or
s:iingD
11.Arterial #RI studies:
o 2 # 5O6
o E # 5O6
o E # !ase contrast
o E# 5O6 gadolinium !ase contrast H 3BS5
o 7s!in eco tecni>ue8 H .lac: .lood tecni>ue" for large a& visuali;ation
o 7gradient eco se>uence8 H .rigt .lood" for smaller a& 0renal" !eri!eral1
H#OD'(A#ICS A(D DOPP$R:
12.He!odyna!ic principles:
Stenosis causes local distur.ances in laminar flow
o 2n fluid" in te stenotic segment velocity KOBS U'
o U!on leaving stenotic segement velocity KOBS #O-N
5is interaction sets off a series of multidirectinal velocity vector forces
5ese vectors are !er!etuated along te course of te tu.e due to inertia 0fluid as
mass1
o 5e more mass fluid as , te more inertia it as
5is leads to tur.ulence and energy losses
o Commonly !ic:ed u! as !ressure dro!Lvelocity dro! off
-it time" tese tu.rulant vectors 0driven .y inertia1 are redirected .y te viscosity
forces into a laminar flow&
2t is an interaction of te disru!ted 6AO- in te stenotic area 0inter!lay .etween
inertia and viscocity of te fluid1 and a given RBS2S5ANCB of a vessel 0defined
.y radius and lengt1 tat will determine ow muc energy 0!ressure1 will .e lost
during tis interaction&
Reflected in Om9s lawC
o Cange in te direction and a.solute velocity will result in energy losses
o S!ar:s 0energy1 fly wen you scra!e0resistance1 te sidewal: at )00 :mL
0flow1
o OmC energy 0'ressure cange1UResistanceVflow
Resistance R= 8L!"
4
o tis re!resents minimum resistance in te circuit"
o determined .y te lengt" radius of te vessel and te viscocity 0# of te
fluid&
5e energy dro! for a given flow will increase if :inetic contri.ution is added H i&e&
if acceleration andLor deceleration is seen in te flow&
age )G
A hemod$nami% &e"sion o' (he )mhs* +a,-
.oiseui++e*s .
i
/.
ii
= 0 1 R= 01 8L!"
4
.
i
/.
ii 2
!ressure or energy cange
S , flow
W H coefficient of viscocity
'ressure gradient across te stenosis is increasedC
o te longer te lesion"
o te iger te density < viscosity"
density or mass determines :inetic com!onent as well" 134&
i

3

o te greater te diameter reduction
Mos( im5o"(an(
-ere can te energy in te flow .e lostD
o Viscocity loss H see 'oiseulle e>uation H te longer" te narrower te
stenosis , te greater te loss
o 2nertial loss H :inetic energy 134&
i

3
This is (he mos( signi'i%an( ,a$ (o +ose ene"g$ in (he %i"%u+a(ion
2n stenotic area" flow increasesX
See ig velocity 4et on do!!ler
&e+o%i($ %hange is seen a( (he en("an%e 6goes u5# and (he e7i( o'
(he s(eno(i% segmen( 6goes do,n#8
9n bo(h %i"%ums(a%es, ene"g$ is dissi5a(ed:
;o i' $ou ha&e 3 s(enosis 3 %m ea%h, ene"g$ +oss ,i++ be M)RE
(han a sing+e 4 %m s(enosis8
To(a+ &as%u+a" "esis(an%e-
CollateralsC
o Com!ensate for te occlusion of main conduit 0iliacLfemLti.1
o 're,e/isting vessels" some are formed in res!onse to y!o/ia
o YonesC
Stem
Mid;one
Re,entry vessels
Segmental resistance 0iliacLfemoral OR collaterals1 P outflow resistance
Segmental resistance increase wit iliacLS6A disease
o Bven multi!le collaterals can never .ring down total resistance to
normal once iliacLfemorals are occludedM
OutflowC com.ined resistance of arterioles" ca!illaries" venules" and veins
-it arterial disease" segmental resistance is increased 0occlusive disease1"
and outflow resistance is reduced as a com!ensation 0dilation at rest1
o ?enceC
#iseased lim.s always ave iger segmental resistance
age )+
Bven wit e/ercise relative dro! in outflow resistance is
SMAAABR in diseased lim.s com!ared to normal
3ecause in tese !atient outflow is ma/imally
dilated at rest
<e"nou++i*s 5"in%i5+e-
Hemod$nami% &e"sion o' (he +a, o' %onse"&a(ion o' ene"g$8
The '+uid*s ene"g$ is de(e"mined b$
o (he e7is(ing ban= a%%oun( 6.i 2 ini(ia+ 5"essu"e#,
o i(s* densi($ > s5eed 6i8e8 =ine(i% ene"g$#
o and e+e&a(ion abo&e g"ound 6g"a&i($#8
Wi(hou( '"i%(ion and ,i(h %on(inous '+o,, (he ene"g$ %on(en( "emains
%ons(an(8
.
i
? 4gh
i
? 134&
i

3
= .
ii
? 4gh
ii
? 13 4&
ii

3
Z H density of .lood
Relationsi! .etween :inetic" gravitational energy and !ressure
o in a frictionless system
Under steady flow" frictionless systemn , energy remains te same&
Re$no+ds numbe"- &e"$ im5o"(an( numbe"
o #imensionless >uantity&
o Re!resents an inter!lay .etween inertial and viscous forces&
o -en num.er is R 2000" local distur.ances are dam!ened .y viscous
forces and flow is laminar&
o R
e
=4&d
i&e& Aaminar flow 0R20001 is favoured in
viscous 0ig W1Llow density 0low Z1 fluids
slower flow 0low velocity V1
smaller diameter of te conduit&
So" if te velocity is increased 0as in stenotic iliac lesion during e/ercise1" te Re can rise
and eventually cross 2000 mar: H turning flow into 5UR3UABN5& 5is translates into
energy losses and !ressure dro! !ast stenosis& Outflow resistance reduction 0due to
ma/imum vasodilation1 is designed to counteract tis .ut can9t fully com!ensate for te
energy loss at te stenotic segment&
Minimum lengt of tu.e needed to turn laminar flow into tur.ulent OR to re,
esta.lis laminar flow is defined as an entrance lengtC
o En("an%e +eng(h- L
7
=@1"1R
e
@=081A
te lengt of te tu.e needed to cange a tur.ulent flow into laminar is smaller ifC
o te radius of te tu.e is small
age )8
o te fluid is more viscous
o te flow is slow

La5+a%e- Wa++ (ension = .1"
Aarger tu.es ave larger wall tension&
Aarger aneurysms are more !rone to ru!ture
#o!!lerC '"eBuen%$ shi'( C'= 3 D
o
1 %os E%
6
o
carrier fre>uency
C H s!eed of sound )*F0 mLsec
[ H angle of incidence
-y factor 2 is in e>uationD
Some say it accounts for two directions of sound travel H to
te moving R3C and .ac: to te receiver
2 tin: it may .e sim!lier tan tatC
Cos is not linear" error inreases wit greater angleC
o Cos 0 , )
o Cos E0 H 0&8G
o Cos F* H 0&+0
o Cos G0 H 0&*
o Cos %0 H 0
So if you :ee! angle at G0" cos of 0 is 0&*" ence multi!lying it .y 2
will yield error factor of ) i&e& no errorM
o 2 degree angle error
2f confuse *8 degrees wit G0 , 'SV assessment is GO off
2f confuse +8 degrees wit 80 H 'SV assessment is )+O off
13. (on)in*asi*e testing o*er*iew:
Bsta.lis clinical indication first
Use to !lan angiogra!y or survey graftsL:nown stenosis
Start wit resting A32 and 'VR&
o 2f tese are a.normal may order targeted arterial du!le/ to see waveforms
and velocities
o 2f A32 are normal .ut clinically sus!ect claudication
Order stress testingLy!eremia
14.Doppler wa*e for!s:
o 'ulse contour H
age )%
normal H tri or .i !asic
6rist wave H
!rograde energy from te cardiac out!ut"
2
nd
wave H reflection from te !eri!eral resistance"
E
rd
wave H reflection is overcome .y te last :ic: of te
!rograde effect of systolic flow&
Velocity increases ra!idly in early systole" reaces !ea:" ten dro!s
off" reversing in early diastole&
2n late diastole" velocity tracing .ecomes !ositive .efore
returning to te ;ero,flow .aseline&
-it increasing vasoconstriction" te reverse,flow
com!onent .ecomes e/aggerated&
o Same seen wit microem.oliM
-it decreased resistance" reversed !ase may disa!!ear H
wave .ecomes .i!asic
o seen normally in renal" celiac" fed state SMA and
cere.ral circulation

A.normal !atternH wit !ro/imal stenosis
3lunt slow u!stro:e )
st
!ase
dro!s 2
rd
!ase
ten E
nd
stage disa!!ears
'ea: !ulsatility inde/ goes downM
Mono!asic waveformC
.lunted wit slow u!stro:e and !rolonged um!
tracing more continuous and less !ulsatile&
o S!ectral analysis H summari;es and descri.es availa.le range of vector velocities
in te vessel&
5e more te tur.ulence" , te more direction and velocity cange
and te .roader te s!ectrum&
Aoo: for te disa!!earance of te clear window under te tracing
o 'resence of reverse flow com!onent is igly !redictive of intact inflow
o A.sence of reverse flow may .e related to oter factorsC
Aow resistance" y!eremia" vasodilators
mono!asic wave due to severe inflow disease&
B/aggerated 2
nd
com!onent H increased outflow resistance 0microem.olism1
?ence te following means are availa.le to analy;e waveformsC
.ea= (o .ea= 5u+sa(i+i($ inde7
age 20
o '5' fre>uency difference of te #o!!ler waveform divided .y te mean
fre>uency
i&e& !ea: of systolic first wave P !ea: of te reflected 02
nd
1 wave in
early diastoli of te same cycle
NO5 !ea: to !ea: of two different cycles
o 2n normal lim.s" '5' increases from !ro/imal to distal
3ecause MBAN !ressure dro!s in !eri!ery
o 'rovides good descri!tion of !ro/imal inflow lesionC
i&e& first wave is .luntedLdecelerated and reversed wave is reduced
o -it !ro/imal stenosis" tis increase from !ro/imal to distal is not seen
o B&g&
NormalC C6A )E ,Q distal )8
Aortoiliac occlusion 2,QF
S6A occlusion G,QF
.ot E,QE
'ressure 'ulsatility inde/ H if Q F in C6A H li:ely rules out aortoiliac disease
o A.normal value H inter!ret wit caution
Aa!lace wafeform transformation
'ower fre>uence s!ectrum analysis
'ulse transit time
5ese evaluate lesion indirectlyM 'referred metod is direct e/amination of te lesion
wit 3,modeLwave form analysis&
)*& Critical stenosis + residual radius and surface area of t"e
lu!en:
5e cange in energy content of te flow is a function of radius of te vessel raised
to te F
t
!ower AN# velocity of te fluid&
o 'oiseuelle9s e>uation
2nitially" wit small reduction of radius" te energy 0!ressure1 loss is small"
owever !ressure dro!s e/!onentially wen critical radius reduction is reaced
o *0O radius or +*O surface area
o 3ot due to velocity cange AN# radius cange
At tis critical !oint" 'ressure dro!s !reci!itously H i&e& critical stenosis is reaced&
2n sim!le terms" narrowing at wic !ressure and flow .egin to .e affected&
#oes not a!!en until *0O diameter reduction is reaced
o e>uivalent of cross,sectional area of +*O
age 2)
16.Resting A,I + ad*antages and disada*antages:
o Advantages of resting A32C
Suic:" easy" cea!
B/cellent 'rognostic survival info 06ramingam study1
Re!roduci.le
Can .e used to follow and assess effect of t/
0min 0&)* cange is clinically sig1
o Aimitations of resting A32C
#oes not locali;e occlusive disease !recisely
#oesn9t measure internal iliac and !rofunda 0i&e& non,a/ial arteries1
#oesn9t detect multilevel disease
#oesn9t relia.ly !redict !ro.a.ility of trom.otic e!isode in
graftL'5A site
#oesn9t detect occlusion distal to an:le
Unless measure 5oe 3racial 2nde/
artificial elevation in calcified vessels
Renal 6ailure and #M H i&e& false negative is !ossi.le
can9t use in large wounds
Sources of errorC
Cuff si;e 0need to .e at least *0O larger tan lim. diameter1
Aarge collaterals will elevate A32
?5N and CO variation
o A32 is an e/cellent !redictor of CV mortalityC
Additional notes on A32C
'ressure difference .etween #' and '5 sould .e less tan )0 mm ?g& Q )* H
sus!ect stenosis
An:le !ressure Q .racial !ressure .y )2,2F mm
o augmented systolic !ressure .ut diastolic is less
age 22
o mean !ressure is same
ow to 2# A32 in calcified dia.etic footC
o elevate foot
o note disa!!earance of distal #o!!ler signal
o multi!ly distance in cm .y 0&+E*
A32s
o #on9t measure non,a/ial !ressure
o #o not distinguis vasos!asm vs stenosis
o #o not !ic: u! non,flow limiting lesions in trauma
2n trauma" Q 0&% H no need to angio
Additional notes on 'VRC
Reflect total volume of te lim.
2deally measure u!!er" lower ting an calf
o Normal , Calf am!litude e/ceeds tig am!litude .y 2*O
2f not H sus!ect S6A occlusion
o 2naccurate for aortoiliac disease
Unless use 2 tig cuffs
o Accurate for femoral lesions BVBN wit aorto,iliac disease
u!!er tig !ressure
o .y cuff, always e/ceed .racial .y E0,F0 cm
age 2E
5ig 3racial inde/ )&E,)&F
?owever" direct 0invasive intraarterial1 !ressure is same as
.racial
2f cuff !ressure is same or less H sus!ect significant aortoiliac
stenosis
'ressure gradient .etween levels Q E0 mm ?g H suggest o.struction
o U!!er tig !ressure 0!rofunda AN# S6A1 vs lower tig !ressure
Sould .e same
2f different .y )* mm H S6A disease
?ori;ontal difference Q 20 mm is significant
Multilevel disease is difficult to distinguis on 'VR
17. Stress testing and A,I:
B/ercise increases cardiac out!ut and flow troug te aortaLiliac system& 2f te velocity is
increased 0as seen in stenotic iliac lesion during e/ercise1" te Raynold9s num.er can rise
and eventually cross 2000 mar: H turning flow into 5UR3UABN5& 5is translates into
energy losses and dro! in !ressures !ast stenosis& Outflow resistance reduction 0due to
ma/imum vasodilation1 is designed to counteract tis& ?owever it can9t fully com!ensate
for all te energy loss at te stenotic segment&
AdvantagesC
o Uncovers lesions tat are asym!tomatic at rest
!articularly in te iliac system
o Allows to esta.lis functional significance of te lesion
o Allows com.ined assessment of wal:ing a.ility and restriction im!osed .y
orto!edic" neurologic and cardiol!ulmonary disease
'rinci!leC
o Normal individuals do not dro! A32 after * min&
o Magnitude of dro! reflects degree of o.struction
5ecni>ueC
o Su!ine for 20 min" .aseline A32
o 2 m! at )0O incline wal: for * min OR until claudicationLrestriction
o Su!ine !osition H remeasure A32 > 2 min until !re,e/ercise value acieved
OR 20 min ela!sed&
Oter facts on B/ercise testingC
age 2F
o #o not use in CA2" cardiac cri!!les
o 'ost e/ercise H re,measure .racial !ressure H it usually rises" so need to
esta.lis new .aseline&
o 5e more !ro/imal te o.struction" te greater te effect of e/ercise on
an:le !ressure
o An:le !ressure R G0 mm !ost e/ercise H test is !ositive
o Reactive y!eremiaC
Su.stitute for e/ercise
E,+ min su!rasystolic !ressure on tig
Monitor an:le !ressure at )* sec ten E0 sec interval
Normal res!onse H initially dro!s to 80O .ut comes .ac: to
%0O witin E0,G0 sec&
5oe !ressures
o Assessment of functional severity
o Sows degree of ma/imal dilation of !eri!eral .ed
o rea!!ear almost immediately" .ut wit 2 fold
increase in am!litude&
o A.normal H toe !ressure does not come .ac: for Q
)20 sec
o #irect !ressure and 'a!averin H E0 mg intraarterial H Q 20 mm !ressure
dro! significant
Surgical sym!atectomy and y!eremia res!onceC
o 2f !osty!eremia res!onse H twice !rey!eremia H may .enefit from
sym!atectomy
Measures an a.ility to dilate in res!onse to a release in vascular
tone
Not a test of integrity of sym!atetic system
age 2*
5o cec: functionC
o 'VR will decrease wit dee! .reat if sym!atetic is
intact
18. xtre!ity arterial duplex and stenosis:
o No stenosisC !sv R)*0" ratio " )&*
o E0,*0O C !sv )*0,200" ratio )&*,2
o *0,+*OC !sv 200,F00" ratio 2,F
o Q+*OC !sv QF00" ratio QF
o Mono!asic non,continuous staccatoLtum! !ro/imal to stenosis 0no
diastolic1
o Mon!asic continuous flow distal to stenosis
Artery Normal #iameter in 3 mode Normal 'SV
B2A 8 mm )20 cmLsec
C6A 8 mm ))* cmLsec
'ro/imal S6A G mm %0 cmLsec
#istal S6A *&* mm %2 cmLsec
!o!liteal * mm +0 cmLsec
Aortoiliac and !eri!eral waveform in stenosis
o )00O 'SV ste! u! 0velocity ratio 21 com!ared to normal segment
!ro/imally is significant
o 3est accuracy H ratio 2&*,E
o Color do!!ler witout velocity waveform analysis is !oor at >uantifying
stenosis
age 2G
2nflow !ro.lem 0low am!litude" reduced u!stro:e1
Outflow stenosis 0no distal flow" no diastolic flow1
Normal u!!er e/tremity
waveform
age 2+
R su.clavian stenosis
19.-enous graft follow up:
o RF* cmLsec" no diastolic flow H !redictors of early failure
RF* cmLsec .ut normal flow may .e seen in large diameter vein
o Surveylance of grafts im!roves !rimary assisted !atency .y 20O
o 2ntervene if 'SVQE00" ratio Q E&F
20.%"y does steal after fe!)fe! or ax).ife! occur rarely?
3ecause usually te inflow is NO5 limitedM
o -it am!le inflow" .ot receiving .eds receive ade>uate .lood su!!ly
o 5ere is increased 0dou.le1 flow in donor artery if outflow is increased
o 5e flow is distri.uted to eac e/tremity
according to te resistance in eac
wic is more or less e>ual under normal resting circumstances
Vascular steal arises wen 2 run off .eds wit different resistance are su!!lied
.y a +imi(ed sou"%e o' in'+o,
o Com!etition arrises
o 2f inflow is limited" te run off .ed wit less resistance will ta:e te
flow !referentially over te oter .ed rendering it clinically iscemic
o -it !resence of 'V#" te overall resistance of diseased lim.s is ig
ig segmental resistance" ma/imally dilated outflow .ed
resistance tat can9t dro! its resistace more wit e/cercise
o ?ence initially iscemic lim. may .e rendered even more iscemic
21.Carotid ultrasound + %as"ington/ (ASC& and CS& criteria
o -asington criteria H .ased on BCS5" NO5 NASCB5 angiogra!ic
correlation
BCS5 H outlines y!otetical normal carotid .ul. and measures
stenosis wrt tis
NASCB5 H com!are distal 2CA to stenosis
May get negative stenosis figures
Com!ared to BCS5" !redicts less severe stenosis
age 28
o Angiogram H underestimates stenosis
o MRA !ro.a.ly e>uivalent to du!le/ US
o ?ig sensitivity study
A.le to recogni;e an a.normality
needed for sym!tomatic !ts
o ?ig s!ecificity study
a.ile to recogni;e normal artery
needed for asym!tomatic !ts
Washing(on F"i(e"ia
o Remem.er tat it OVBRBS52MA5BS te stenosis 0BCS5" not NASCB5
criteria1
o Remem.er" tat it gives ranges tat do NO5 a!!ly for AN= study H i&e&
NASCB5 0+0O stenosis 1 and ACAS 0G0O stenosis1
o NormalC no !la>ue" smoot walls" .oundary layer se!aration in .ul.
o R )* O mild S3
o )G,F%O mar:ed S3" no systolic window
o *0,+%O 'SV Q)2*" '#V R)F0 cmLsec" mar:ed S3" 2CALCCA Q )&8
o 80,%%O 'SV Q)2*" '#V Q )F0 cmLsec" !oststenotic tur.ulence" 2CALCCA
Q E&+
o OcclusionC no flow
May .e wrong in EO of cases H ence AA-A=S confirm tis wit
angio or MR2&
2n measuring carotid velocityC
o :ee! gain low H may artificially cause S!ectral 3roadening
o :ee! sam!le volume low 0)&* mm1
o notice !ost,stenotic tur.ulence and color flow mosaic
22.(or!al Carotid and -erte.ral flow *elocities:
o CCA
No defined a.normal 'SV
age 2%
Normal flow most of te time R)00 cmLsec
2f #ecreased& 6irst com!are R and A
o 2f .ilateral H aortic stenosis or myocardial failure
o 2f unilateral
CCA origin stenosis H all velocities !ast CCA
are dam!ened
2f elevated
o ?y!erdynamic state if .ilateral
o rLo contralateral CCAL2CA occlusion
com!ensatory flow
flows increase from arc to CCA .ifurcation
%cmLsec !er cm
Measure CCA 'SV for ration at a #B62NB# location
o Usually F cm .elow .ifurcation
o -idt of a trasducer
o 2CA H normal velocity *F,88 cmLsec
o BCA H normal velocity ++,))* cmLsec
No criteria for stenosis
Sus!ect stenosis if Q)2* cmLsec and !ost,stenotic tur.ulence
See notc wit tem!oral ta!
o 2CA and BCA sould AOOI and SOUN# different
2f not" sus!ect 2CA occlusion and confusion of .ranc of BCA for
2CAM
o Normal verte.ral flow
RG0 cmLsec
age E0
2ncreased flow seen in
#ominant verte.ral 0MC on te A1
Near occlusion of 2CA
23.Consensus panel on 0S criteria on stenosis:
o 5ese are more !ractical ten -asington H .ased on Nascet tecni>ue and
range of measurements of stenosisC
o R*0O
'SVR)2*
B#VRF0
Ratio R2
o *0,G%
'SV )2*,2E0
Visuali;ed !la>ue
B#V F0,)00
Ratio 2,F
o Q+0
'SV Q 2E0
Visi.le !la>ue
B#V Q )00
Ratio QF
Aside notes on A.normal velocitiesC
6alse elevation in 2CA 'SV C
age E)
o Contralateral occlusion
o ?y!erdynamic state
o 3ad angle
o 'ost stent or endarterectomy
'SV in carotid stentC
o Q)*0 cmLsec is NO5 Q*0O stenosis
o 'svQE00 and B#V Q )F0 H !redicts ig grade stenosis .ut need angio to
confirm
Carotid occlusion
o -aterammer waveform 0sar! u! and .elow ;ero line downstro:e" no
diastolic flow
o Acute trom.us
o No flow in 2CA
o 2n imagingC
Use !ower #o!!ler
2f !ulsedC
Iee! '6R low to detect low flows
2ncrease #o!!ler gain to 2# slow velocity
2nnominate stenosisC
o #ecreased CCA wave
o Reversal of flow in 2CA and CCA
Croucing .unny waveform
o Carotid steal can only a!!en on R side
See reduced 'SV in 2CA" reversal of flow in diastoli
Aong severe stenosis in 2CA will ave reduced 'SVs" not eleavated&&&
age E2
o ?ence always rely on ratio 2CALCCA in tese cases&
o Ma:e sure CCA is not elevated 0i&e& Q)00 H due to cLl occlusion
24.Ot"er useful *elocities !easure!ent for carotids

o QG0O stenosis H e/ternal Oregon validation wit angio
'SV Q2G0" B#V Q+0" ratio Q E&2&
Accuracy %0O
o NASCB5 Q +0O stenosis
'SV Q280" B#V Q 80" Ratio QF
''V %*O
o Q80O stenosis
'SV Q2*0" ratio QF
%0O accuracy for +0,%%O range
o 2ntrao! du!le/ assessment of CBA
Re!air if 'SVQ200
o Su.clavian artery stenosis
Retrograde 0notced1 verte.ral flow
o No graded 'SVs values vs occlusion for verte.ral artery flows
o Verte.ral stealC
See eiter reversal of flow or stalled flow
're,steal , 3ac: 0systoly1 and fort 0diastoly1
#on9t confuse wit !asic flow in verte.ral vein
age EE
25.1re2uency of Sur*eylence of known stenosis
o Asym!tomatic Q G0 stenosisO
2f 'SVR)+* cmLsec
'rogression is FO over 2) monts
2mage annually
2f 'SV Q )+*O
'rogression 2GO over )F monts
?ence image > G mont
26.&ranscranial Doppler
o Color flow" 3,mode" !ulsed #o!!ler
o 2ndications
Bvaluate cere.ral vasos!asm 0!ost SA?1
3u..le study 0for !atent foramen ovale1
Screening cildren wit sic:le cell disease 02 don9t :now wat tat
means1
D inrao! monitoring and assessement for sunt need
Dearly diagnosis of y!er!erfusion syndrome
Need to :now MCA flow !reo!
2f see 2 fold increase in mean velocity H ave your diagnosis
Not cost effective to 4ustify routine use
5ere is NO indication for 5C# in routine carotid US
o ?ow to doC
2 M?;
age EF
5ranstem!oral window and su.occi!ital window
2# MCA" ACA" ')" '2
Ket mean 0not angled corrected1 velocity H assume 0 degrees
correction
NUE0,80
Vasos!asm Q )20
o 6or R'V2 e/am" you ha&e (o =no, wat arteries are sam!led in wic
window and te direction of flow in tese areteries H away or toward te
transducer
Ai:e" you are going to need to use tis in real lifeM
27. Renal artery 0S
o #o clinical !rofiling first
Atero , Q*0yoa" R6" ?5N
6M# H young female wit ?5N
o Overnigt fast
o Aongitudinal view of su!raceliac artery first
Convert to transvers
2# A renal vein
2# origin of .ot renal aa&
2mageC
Orifice
'ro/imal
Mid
#istal
2nterlo.ar and arcuate flowsC
age E*
o U!!er !ole
o Mid !ole
o Aower !ole
Measure :idney si;e
o Com!are si;e" Q )&* cm difference significant
o R % cm !ole to !ole suggest atro!y
o 2ndirect measurements of flowC i&e& measure random artery in !arencyma
NO5 !ros!ectively validated
Resistive inde/C 0),B#VL'SV1
2f Q*O .Ll difference" diagnose *0O stenosis
Not wor: if .ilateral disease
R2 R0&8
%GO sensitive
*EO s!ecific
5o !redict im!rovement in renal failure !ost stenosis re!air
R2 Q 0&+* AN# B#V R%0
May get reduction of *PL,* mm ?g !ressure
Ai:ely NO clinical .enefit
5RANS'AAN5B# :idney
R2 Q 0&8
o ''V 88O" N'V %EO to !redict deat" need for
dialysis and Cr clearance deterioration
o Normal flow H low resistance" 'SV R)80 cmLsec
o Stenosis
age EG
RAR Q E&* , G0O stenosis
8FO sensitivity
%+O s!ecificity
''V %FO
'ros!ectively validated
'SV Q200 cmLsec , G0O
3ut wit RAR is MORB !redictive H i&e& can diagnose G0 O
stenosis if RARQE&* regardless of 'SV value
o #u!!le/ of renal artery H CAN95 see accessory arteries
o Renal artery aneurysmC
Associtated wit
Vasculitis
6M#
#issection
macroaneurysm
28.#esenteric duplex
o Screen for CM2
o G fast
6astingC Aow flow" ig resistance
6edC ig flow low resistance
o 2,F M?;" su./i!oid and R lateral 0liver window1
o SMA
'SV 2+* cmLsec H +0,)00O stenosis
B#V ** cmLsec , Q *0O stenosis
o Celiac
age E+
?ig flow" low resistance all te time
'SV Q200 cmLsec
B#V Q** cmLsec
Retrograde flow in C?A if celica is stenosedLoccluded
#ifficult to assess flow in celic if SMA disease is !resent
-it median arcuate syndrome" 'SV goes u! wit BJ'2ration"
normali;es wit ins!iration&
o C?A
Normal 'SV G0,)2*
Aow resistance
o 'ortal vein
2n fasting state H 'SV 8,)8
o Varies +0,)00O in si;e wit res!iration
o Kradient wit 2VC *,+ mm
o 'ortal y!ertension
Si;e Q)E cm
Slow flow
6low away from liver 0e!atofugal1
2n N" sould see same direction of flow in C?A
29. 0S and -AR
o Most of te time useless H difficult to get good !ictures
o Bndolea: ty!e 2
2f R80cmLsec, li:ely to trom.ose
2f Q)00 cmLsec unli:ely to trom.ose
age E8
30.0ltrasound of Transplant:
o Aiver
?e!atic artery stenosis
#ifficult to get true angle 'SV
'arvus tardus most common finding in stenosis
o A5 Q0&0E" R2 is less tan one
5rom.osis H emergent e/!loration 0.ile ducts de!end on it1
?e!atic artery s!asmC
?ig resistive flow
Reduced 'SV" no flow in diastoly" may .e reversed flow
R2 is )&0
o IidneyC
Renal a& stenosis H
'SV Q200" renal H iliac ratio Q )&8
On intrarenal s!ot testing H tardus !arvus H A5 Q0&)
Blevated R2
Renal VB2N trom.osis
6luid collection
O.struction
Re4ection
A5N
#rug ne!roto/icity
2ntrarenal AV6
'ost .io!sy
age E%
Rare cause of iscemia" may cause tn
31.0ltrasound and c"ronic *enous insufficiency
o #u!le/ assessment
rLo #V5
assess outflow
augmentation studies
dee! and su!erficial flows" !erforators
reflu/C lying and standing !lus cuff
rLo AVM
o AV'
Am.ulatory venous !ressure
Venous !ressure measured directly in dorsal vein after )0 di!,toes
0)Lsec1
Calf contractions increase outflow
o Strain gauge 'letysmogra!y
Used for #V5
Not anymore
Assess .aseline value
Measure increase in volume after calf contractions
N 2,EO cange a.ove
2f outflow !atology H see R 2O volume reduction
o 2m!edance !letysmogra!y
6or #V5
Not used anymore
age F0
32. C"aracteristics of *enous flow:
o 'asic
2f continuous H sus!ect !ro/imal o.struction OR collaterals from
!rior #V5
2f !ulsatile H sus!ect R?6" fluid overload" AV6
2n u!!er e/tremity" it is NORMAA to e/!ect to see some
!ulsatile flow .ecause of !ro/imity to te eart& 'ulsatility
is A3normal in leg veins
o Unidirectional
o Res!onds to
Res!iration
Valsalva
Com!etent valves
age F)
2ncom!etent vein
AV6 in leg veinC !ulsatile flow
Continuous flow H outflow o.struction
33. 0ltrasound and Dialysis access
o Normal graft velocities
'sv )*0,E00
Bdv G0,200
Mar:ed s!ectral .roadenings
critical velocity in dialysis graft 'SV R)*0 cmLsec
normal flowC
o Q800 ccLmin
o early stenosis *00,800 ccLmn
o severe stenosis R*00 ccLmin
age F2
A&HROSC$ROSIS 3 RIS4 1AC&ORS5 &6:
34.P"ysiologic role of endot"eliu! :
o Normal endotelium functionC
Modulator of coagulation system
?e!arin" t'A" trom.omodulin
'ermea.ility .arrier for nutrients<fluids
Ai!ids" glucose" water
'ermea.ility .arrier to cells
Regulates inflammatory res!onse
Normally Nonaderent surface for !!tLneutro!ils
o Regulated .y 2CAM" VCAM rece!tor e/!ression
2ni.it SMC !roliferation witin intima
o 5K6. H transforming K6
angiogenesis modulation
VKB6 to grow new vessels
Vascular tone modulation
NO < !rostacyclin vs endotelin < angiotensin
o Bndotelial !roductsC
B#R6 0NO1 < 'rostocyclin , dilating
Angiotensin and endotelein H constricting
5!a" e!arin" trom.omodulin
o -at damages endotelium
Mecanical < low Seer stress
Meta.olic stress H e/cess of A#A" glucose
2mmunologic stress , infection
Vasoconstrictor stress
smo:ing
35.1actors i!portant for at"erosclerotic pla2ue de*elop!ent:
o Sear stress
o 6low se!aration and stasis
o 5ur.ulence and Oscillation of sear stress vectors
o ?y!ertension and ?eart rate
5ese contri.ute to tur.ulence and seer
low ?R , less aterosclerosis in carotids
ig ?R H less ateroscleosis in infrarenal aorta
o structural disorders H !seudo/antoma elasticum
age FE
o vasa,vasorum o.literation < fi.rosis H due to radiation
36.Role of !acrop"ages in at"erosclerosis/ list !acrop"age
secreted 71:
o 2n4uredLaltered endotelium e/!oses adesion molecules tat attracts
monocytes
o Monocytes migrate into su.endotelial s!ace and turn into macro!ages
o M'? !ic: u! o/idi;ed A#A H turn into foam cells
o 5is u!ta:e causes M6 to syntesi;e
Monocyte colony stimulating factor 0M,CS61
Kranulocyte colony stimulating factor 0K,CS61
e!idermal K6 0BK61
!latelet derived K6 0'#K61
transforming K6 al!aL.eta
Vascular endotelial K6 0VBK61
monocyte cemoattractant !rotein ) 0MC' )1
o more monocytes are attracted" !la>ue starts to remodel
37.%"at "appens in at"erosclerosis:
o 'rimarily an BN#O5?BA2AA disease tat s!ills over to te media
o Bndotelial in4ury OR alterered !ermea.ility to li!o!roteins first
o more adesive molecules formed
2CAM" 'BCAM H !!t and -3C movement into vessel wall
o cyto:ine !roduction .y endoteliumC '#K6" 6K6R 5K6." 2A )
local cells 0SMC1 and new arrivals 0monocytes1 are transformed
and caused to !roliferateLmove to intima
monocytes form mast cells ,Qfoam cells
o li!id accumulation in foam cells" wic later s!ills outside to te media <
around SMC
o li!id core is formed under endotelium
o collagen and connective tissue is formed ,Qfi.rous !la>ue
o !la>ue can ru!ture , Q
leading to luminal trom.osis and ateroem.olism
38.Stages in at"erosclerosis and types of pla2ues:
)& 2solated 6oam cells
a& transformed monocytes,Qmacro!ages wit li!id
2& fatty strea: 0collection of foam cells1
E& fat accumulation outside of foam cells
a& li!id dro!lets 3B5-BBN SMC distorting teir arrangement in media
age FF
F& formed li!id core in 2N52MA
*& toug fi.rous ca!
G& ru!tured ca!Lcom!le/ ateroma
39.(a!e different !ediators secreted .y endot"eliu!:
o 'rocoagulant H !lasmingen activator ini.itor 0'A21" von,-ille.rant 6actor
o Anticoagulant H e!arin" trom.omodulin" t'A
o Vasodilator H !rostacyclin" NO
'rostocyclin also increases cAM' 0reduces !lt aggregation1
o Vasos!asm mediator H angiotensin 2" endotelin
40. ndot"elial progenitor cells:
6ound in circulation
Released .y 3M in res!onse to iscemia and trauma
Ca!a.le of endotelial re!air" serete t'A
#ecreased in !t wit cardiovascular disease and smo:ers
'resent in .ot young and old
41.#ec"anis! of action of (itric oxide/ or ndot"elial Deri*ed
Relaxing 1actor:
o Smoot muscle rela/ant
o 2ni.its !!t and -3C aggregation
42.ffects of s!oking:
?istologically" smo:ing damages endotelial cellC
o swelling"
age F*
o .le. formation"
o su.endotelial edema"
o tic:ening of .asement mem.rane"
o widening of endotetelial 4unctions&
increases viscocity and decreases o/ygen trans!ortC
o car.o/y?K due to CO wic leads to increase in ematocrit
o aggregation of -3C and !tt
o fi.rinogen content in .lood increases
5ese events lead toC
o 2ncreased trom.ogenicity
#ue to increased viscosity due to increased ematocrit
#ue to decreased fi.rinolytic ca!a.ilityLincreased fi.rinogen
#ue to direct endotelial in4ury and vasos!asm
o due to decreased NO !roduction
o due to increased !latelet aggregation
o Altered Ai!id meta.olism H decreases ?#A" u!ta:e of A#A increases
o Reduced o/ygen deliveryC
#ue to increased car.on mono/ide
SummaryC
Affects AAA functions of endotelium
2ncreases trom.ogenicity
o 2ncreases viscocity of .lood
o 2ncreases fi.rinogen
#ecreases o/ygen delivery 0car.on mono/ide effect on ?g1
Affects li!id meta.olism
o A#A u!" ?#A down
43.#ec"anis! of action of Angiotensin II:
o Vasoconstrictor
o 2nduces inflammatory cyto:ine 2A G
o Releases aldosterone
o Releases A#?
o 2ncreases sym!atetic tone
o Vessel and myocardial wall y!ertro!y
age FG
44. ACI effects:
o MecanismC
ini.its conversion of A5 2 to A5 22
u!regulates .rady:inin H
o causes coug and vasodilation
ini.its aldosterone
ini.its A#?
increases AV contractility
remodels myocardium and vessels
A#A o/ygenation reduction
numerous !leotro!ic effects on endotelium 0SMC
ini.ition" NO induction" !!t adesion ini.ition1
)GERALL EDDEFT;- TR9..ED )HT an(ih$5e"(ensi&e

o Reduces ris: of M2" CVA" deat due to CV cause 0?O'B1
o 2n acute M2C decreases deat" !rogression to C?6 and need for
os!itali;ation due to C?6 0A2RB1
o Com!ared to oter anti y!ertensive meds" in dia.etic !ts ave 3B55BR
!revention of !roteinuria"
ne!ro!aty !rogression"
!reservation of renal function"
control of ?5N&
o ContraindicationsC
age F+
:nown y!ersensitivity
life treatening angioedema
5"egnan%$ 6(e"a(ogeni%#
bi+a(e"a+ RA; or sole :idney RAS 0A5 22 is needed to
maintain K6R H ACB2 will cause acute R61
aortic stenosis
?y!ertro!ic Cardiomyo!aty H ris: of y!otension from
fi/ed outlet o.struction
45. %"at are t"e effects of statins?
Colesterol lowering , reduce A#A and im!rove ?#A
'leotro!ic effects H BJ5RBMBA= im!ortantC
o 'ositive effects seen in !eo!le wit NORMAA colesterol
o Sta.ili;e !la>ue
o Reduce macro!age activity in te !la>ue
o Cause !la>ue fi.rosis
Ru!ture !rone 0ecolucent" li!id laden1 transform into toug sta.le
!la>ue 0eogenic" fi.rous1
o Nutritive effect on endotelium tat canges !rocagulantLanticoagulant
!ro!erties of endotelium
Reduce venout trom.oem.olism
Sta.ili;e AAA and reduce teir growt 0yes" sir1
Overall" reduce stro:e" reduce CV mortality&
46. 8upiter trial/ 9::;:
'ts wit normal li!id !rofile .ut ig CR'
Males Q *0 yoa" females Q G0 yoa" NO istory of #M" CVA" M2
)+"000 !ts randomi;ed to !lace.o vs 20 mg of rosuvastatin
At 2 years trial sto!!ed
2m!ressive reduction inC
o in te various com.ined end!oints" wic included stro:e" eart attac:"
angina" and .y!ass surgery 0FFO1&
o com.ined end!oints of stro:e" myocardial infarction" and cardiovascular
deat 0F+O1 as well as a
o reduction in total mortality 020O1&
age F8
47.%"at !ec"anical factors can in<ure endot"eliu!?
o Bm.olectomy cat
o '5ALwire
o Bndarterectomy
o Valvulotomy
o Overdistension of vein graft
o Anastomosis construction
48.Steps in inti!al "yperplasia de*elop!ent:
o Bndotelial in4ury
o Coverage of denuded area .y car!et of !latelets
o '!ts release K6
'#K6" BK6" 6K6
o Krowt factors stimulate endotelial AN# smoot muscle cell !roliferation
o 'latelets are dis!laced .y neo,endotelium
o Medial SMC !roliferation caused .y !latelet K6
o ;MF mig"a(ion a%"oss in(e"na+ e+as(i% memb"ane in(o in(ima
o Iene"a(ion o' e7"a%e++u+a" ma("i7 b$ ;MF in ini(ima
age F%
2n te end" luminal diameter is decreasedM
49. How can inti!al "yperplasia .e pre*ented=treated?
o Anti!latelet agents H ini.it !latelets , mediators of y!er!lasia
ASA" K' 223222A" !lavi/
o Seeding of grafts wit endotelium H e/!erimental" only !ro/ and distal
ends of te syntetic graft are seeded&
o 2ni.it SMCC
#rugs H sirolimus" tacrolimus
Aocal irradiation
Nitric o/ide
Kene tera!y
o 6urter surgical reconstructionC animal studies suggest tat 2? is self,
limiting , on%e %om5+e(e, "ene,a+ o" %on(inued h$5e"5+asia is un+i=e+$ 2
hen%e su"gi%a+ "e%ons("u%(ion o' s(enosed g"a'( is 'easib+e8
50.How can R1 for at"erosclerosis .e !odified:
o #M control H diet" e/ercise" medication" weigt loss" foot care
Reduces M2Ldeat due to vascular causes
UNCABAR if it !revents !rogression of ulcers"
No eveidence it !revents am!utations or infections
o ?5N H diet" e/ercise" medication
decreases
o all cause mortality .y )2O"
o stro:e mortality .y EGO"
o coronary mortality .y 2*O
o #isli!idemia H diet" e/ercise" medication" weigt loss
sta.ili;e !la>ue and !rogression of 'A#
o F0O reduction in !rogression of 2C
for every )0O reduction of total colesterol" )*O reduction
in mortality
im!roved !atency of infrainguinal .y!ass
o Smo:ing H cessation !rogram" drugs" su!!ort grou!s
alt claudication ,Q rest !ain !rogression
im!roves !atency of revasculari;ation !rocedures
im!roves survival
no evidence it im!roves sym!toms of 2C
o y!eromocysteinemia H .y diet and folate
im!act un:nown yet
age *0
51.&arget for lipids:
2deally A#A R E mmol
?#A Q ) mmol
?owever" if ris: for CA#
low H A#A R * mmol" 5CL?#A R G
moderate H A#A RE&* mmol" 5CL?#A R *
ig H A#A R2 mmol" 5CL?#A RF
2f ave #M H A#A R 2 mmol
52.PAD and risk reduction:
o Aife style modificationC
-eigt loss
B/ercise
Cease smo:ing
Control ?5N
Control Ai!ids
Control #M
o S!ecific #rugsC
'latelet ini.itorsC
ASA" COJ ini.itor"
o limits !roduction of trom.o/ane A2
o inflammation" !latelets9 aggregation and vasoconstriction is
limited
o 'latelets are affected irreversi.ly
o endotelium >uic:ly regenerates
!rostacyclin secretion is restored&
5is a!!ens wit low dose ASA H
B/!lains .etter small dose effectiveness com!ared
to a large dose&
o given !erio!" see reduction of CA3K failure .y )0O
Clo!idogrelL!lavi/LticlidC
o A#' rece!tor ini.itor
o 'revents activation of K'22.L222 a com!le/
An A#' de!endent !rocess
o A#'LcollagenL!latelet activating factor 0'A61< adenosine
induced !!t aggregation is limited
K' 22.L222a rece!tor ini.itor H
o used !ost cardiac stents"
o ini.it .inding of fi.rinogenLv-6 to te a.ove named
rece!tor
o !ossi.le anti SMC effect
age *)
vasodilatorsC
cilosta;ole" )00 mg .id"
!os!odiesterase ini.itor"
o increases cAM' in !!ts
o reduces !!t aggregation
o increases SMC rela/ation&
C2 in C?6&
SLeC nLv" diarrea" ras" di;;iness" !al!itations
reologicC
!ento/ifylline H
o )200 mg od"
o increases R3C deforma.ility and decrease for
viscosity&
o 20O im!rovement in claud distance in some
studies over GL)2&
sLeC nLvLdi;;iness
ACB2
VesselC
o #ilates 0troug NO1
o Remodels 0SMC effect1
'latelets
o Reduces aggregation
Ai!id
o #ecreases A#A o/ygenation
Renal !rotection
Controls ?5N 0anti aldosterone and A#? effect1
StatinsC
VesselC
o Remodels via effect on SMC
!roliferation and migration ini.ition
o 2m!roves endotelium function
'lateletes
o Reduces aggregation
Ai!id
o Reduces colesterol
o Reduces A#A o/idation and u!ta:e
Reduces insulin
2ncreases fi.rinolysis\
AS2#BC
age *2
Osler notesM
Ro+e o' an(i5+a(e+e(s, s(a(ins and AFE inhibi(o"s in (he managemen( o'
5a(ien(s ,i(h 5e"i5he"a+ a"(e"ia+ disease&
tt!CLLves&sage!u.&comLcgiLre!rintLF0LFLE)2 , v& useful article !lus 5ASC
Anti!latelet tera!yC inactivate !latelets tus lowering trom.otic com!lications of 'V#
associated wit ulcerated !la>ue ru!ture& May ave .enefit in maintaining !atency of
!rostetic grafts&
BvidenceC 2n !ts wit 'A# !articularly as it was sown to decrease overall reduction in
cardiovascular events& 5is was initially demonstrated in !ts wit 'A# and coe/isting
CA# and Cere.ral arteries #isease 0Antitrom.otic 5rialist9s colla.oration 02*O
reduction in CV events1N and later confirmed for all su.grou!s of !ts wit 'A# 02EO odds
reduction1& Com!ared to ASA" Clo!idogrel offers 2FO .etter ris: reduction in CV events
in sym!tomatic !ts wit 'A# 0a.solute RR is only )&2O1& Com.ination of
ASALclo!idogrel is re>uired !ost S6A stent insertion to reduce ris: !osto!erative instent
trom.osis& Anti!latelet medications ave .eneficial effect on !atency of !rostetic lower
e/tremity .y!ass graftsC RR of occlusion wile on te ASA tera!y is 0&+8
5e CA'R2B trial e/amined te relative safety and efficacy of daily doses of +* mg
clo!idogrel vs E2* mg ASA in nearly 20"000 !atients wit iscemic stro:e" M2" or
'A#&5e results of te trial sowed tat clo!idogrel was more effective tan ASA in
!reventing te !rimary study end !oint" a com!osite of iscemic stro:e" M2" or vascular
deat& 5e trialists found a significant 8&+O relative,ris: reduction 0P U &0FE1 for
clo!idogrel over ASA&
'ost oc analyses of te CA'R2B trial ave sown tat certain su.grou!s of !atients wit
ig stro:e ris:" including tose wit dia.etes mellitus"tose wit !rior cardiac surgery"
tose receiving concomitant li!id,lowering tera!y" and tose wit a istory of more tan
) iscemic event" received significant advantage from clo!idogrel over ASA& 6or
e/am!le" in te su.set of CA'R2B !atients wit dia.etes" annual event rates for te
age *E
com!osite of vascular deat" M2" stro:e" or reos!itali;ation for iscemia or .leeding were
elevated com!ared wit te rate in nondia.etic !atients" corres!onding to an am!lified
.enefit of clo!idogrel over ASA in tese ig,ris: !atients 02) vs % events !revented !er
)000 !atient,years for tis end !oint1&
StatinsC tey lower A#A" 5K" A'0a1 H factors involved in !atogenesis of aterosclerosis&
Also" tere is evidence tey modulate arterial wall inflammation" !la>ue sta.ili;ation"
endotelial dysfunction"

and trom.osis" reduce fasting insulin concentration&
BvidenceC ?eart !rotective study demonstrated tat F0 mg of simvastatin at * year fLu in
!ts wit 'A# resulted in )2O reduction of total mortality" )+O reduction in vascular
mortality" and 2FO reduction in CA#& 5ese findings led to recommendation to lower
A#A to R2&*% mmolLA& ) mmolLl reduction in A#A is associated wit 20O RR in ma4or
CV events H regardless of te .aseline li!id level 0i&e& including normal range1 and only
de!ended on te .aseline assessment of CV ris:" wit 'A# !ts .eing at ig end of te
s!ectrum&
ACB2 and A5R3C useful ad4unct to 3' management" !articularly in !ts wit dia.etes and
'V#& Moreover" it ACB2 and A5R3 were sown to effect remodeling of te myocardium
and vessel wallC tey sare similar to statins !leotro!ic effect on arterial wall&
BvidenceC ?O'B study demonstrated 22O reduction in CV events in !atients on rami!ril"
inde!endent of te .lood !ressure lowering effects& 5ey ave numerous !leotro!ic
effects on te arterial wall ini.ing SMC migration and !roliferation" o/idation of A#A"
!latelet ini.ition" stimulation of NO secretion&
53.Conser*ati*e !easures of treat!ent of claudication:
Most effective H wal:ing
o Bndotelial function o!timi;ation
o Alters muscle meta.olism 0anaero.ic training1
o Re,trains to use more !ro/imal muscles
o Collateral develo!ment H unli:elyM&
o 2m!roves meta.olism of li!ids and glucose
#rugs H cilasta;ole" !ento/y!ylline 0!lace.oD1
Smo:ing" R6 H no clear evidence tat it will reverse claudication" .ut will
control !rogression of aterosclerosis and !ossi.le conversion to claudication&
o ))O of smo:ers wit 2C will undergo am!utation" com!ared to 0O in
non,smo:ers
o E fold iger ris: of needing intervention if !t as F0 !ac: year of
Smo:ing
o Cessation will im!rove !atency of .y!ass E foldM
Statins H will alt !rogression to CA2 .ut won9t el! sym!toms of 2C
age *F
o F0O reduction in !rogression to CA2
54.DD of claudication:
o Aterosclerosis
o Non,aterosclerotic disease
Coarctation
Bntra!ment
Adventitial cystic disease
'ersistent sciatic a
6M# of B2A
'seudo/antoma elasticum
Bndotelial fi.rosis of cyclists
o mimic:ers
Venous claudication
Cronic com!artement syndrome
'eri!eral nerve !ain
S!inal cord com!ression 0OA1
OA i!
55.Risk factors and !arker of increased risk for P-D:
R6C
?5N
?A
#M
Smo:ing
?omocyseinemia
Mar:ers
CA#
'revious 'V# events
Sedentary lifestyle
6i.rionogen
O.esity
6am /
2nflammatory mediators
!& )8%+
56.%"at en>y!atic deficiency is found in
"yper"o!ocysteine!ia?
o ?omocystein" !roduct of metionine
o E en;ymes
cystatione 3, syntetase 0C3S1
age **
omocysteine metyl transferase 0?M51
metylene tetraydrofolate reductase 0M5?6R1
o omocystein is not fully meta.oli;ed UQ !artial meta.olites accumulate
o omocysteine tiolactone 0?5A1 accumulates
to/ic to endotelium
canges luminal carge
causes cellular aggregation
accelerates aterosclerosis 0A#A meta.olism1
o treatment
folic acid
vit 3G" )2" Coline" 3etain
o tese el! to meta.olise ?5A
folic acid treatment" owever" did not demonstate any effect on CV
mortalityM
SYMPATHECTOMY
57.How does sy!pat"ecto!y work?
o 2ncrease in .lood flow
#ro! in resting vasomotor tone
Most of increase is non,nutritive" via AV sunting
#iminises after * days 0*
t
day !enomenon1
resting vasomotor tone returns to normal in G mont
o Collateral flow increaseC
Average ))O increase in flow in animal models
o Alteration in !ain !erce!tion
Bffective for rest !ain
Central and !eri!eral signal conduction attenuation
Overall , .etween ealing su!erficial ulcer and relief of rest !ain" sym!atectomy
is more li:ely to el! R'C
o needs less increase in .lood flow to relieve rest !ain com!aired
re>uirements for ulcer ealing
o effective !ain im!ulse conduction interru!tion < attenuation
58.Indications for $ower extre!ity sy!pat"ecto!y:
y!erydrosis
Com!le/ regional !ain syndrome
AB vasos!asm , Raynaude9s #2SBASB
o Rare indication .ut res!onds very well
'V#C
age *G
o 2scemic rest !ainC criteriaM&
A32 Q 0&E
A.sent neuro!aty
Aimited tissue loss
o 2scemic ulcerationC criteriaM
A32 Q0&E
Sallow ulcers" non,infected
-ill eal in EEO" .ut won9t !revent am!utation
o As an ad4unct to Arterial reconstruction
'articulary if small vessel anastomosis is involved
#e/tran F0 infusion may .e 4ust as effective for !erioo!
!revention of trom.osis of difficult distal anastomosis&
May not im!rove long term !atency of .y!ass
5ecni>ueC
o Retro!eritoneal dissection
o 2# !soas muscle
o Cain lies over transverse !rocess medial to !soas m&
On te R H under 2VC edge" on te A H lateral to aorta
Remove ONA= A2 ,E
2f remove A) H retrograde e4aculation
AF does noting
Com!licationsC
o 'ost sym!atectomy neuralgia
Seen in *0OX
Anterolateral tig ace
-orse at nigt" unaffected .y activity
Koes away in )2 monts
o Ken,fem n& in4ury
o Male se/ual dysfunctionC
Retrograde e4aculation
2f .ilateral A) sym!atectomy H 2*,*0O
o 6ailure to acieve ade>uate levels of !ain control
59.$u!.ar sy!pat"ecto!y: outco!e ?
o B/cellent outcome e/!ected inC
Com!le/ regional !ain syndrome
y!erydrosis
o goodLfair outcome e/!ected inC
Raynodes
?owever" res!onse is transient M
3uerger9s disease
age *+
Non,.y!assa.le aterosclerotic occlusion wit limited tissue loss
o 'oor outcome seen inC
Claudicants
#M neuro!aty
60.0pper extre!ity sy!pat"ecto!y:
2ndicationsC
?y!erydrosis
CR'S
Raynauds disease 0ig recurrence1
?owC
)& O!en 0transa/illary , !ainful" !araverte.ral H e/tensive dissection" su!raclavicular
H ig incidence of ?orner9s1
2& 5oracosco!icC
Colla!se lung
Visuali;e )
st
F ri.Lverte.ra
2# su.clavian a& H su!erior e/tent of dissection
Sym!atetic cain H dorsal" !renicLvagus nerve H ventral
Remove all sym!atetic ganglia .elow 5) H i&e& t2 and tE&
Aeave stellate ganglion intact H oterwise orner9sC
o U!!er !tosis 0Muller9s muscle denervation1
o Aower u!side !tosis
o Myosis
o PL, enydrosis and loss of cilios!inal refle/ 0nec: !ain H s:in !ric: , causes
i!silateral !u!il dilation1
o No 6acial sweating
Most common com!licationsC
Com!ensatory y!erydrosis 0)00O1
?orner 0u! to F0O1
2ntercostals neuralgia 0E0O1
'renic nerve is NO5 damaged in toracosco!ic a!!roac&
VASCULITIS
61.Raynaud5s:
o Syndrome H
due to occlusive !atology"
may .e unilateral" may lead to ulcers
Associated wit
C5#" aterosclerosis" y!erviscocity" vi.rational trauma
age *8
o %0O , C5# H scleroderma" s4ogren" SAB" RA"
myositis
On /C
rLo 4oint !ain" ras" muscle !ain" systemic s/s"
y!otyroidism" re!etitive trauma" frost.ite" 'A#Ls/s of
5OS
Aa.wor:C
SAB H omogenious ANA
Sclreroderma H s!ec:led ANA
CRBS5 H anticentromere A3
o Calcinosis" raynauds" eso!ageal dismotility"
sclerodactyly" telagectasia
o #isease H
vasos!astic" .ilateral" no ulcers
Btiology is uncertain
'rimary !ro.lem is on BN#O5?BA2AA level
o More vasos!astic tan rela/ing
B/aggerated res!onse of SMC to sym!atetic stimulation
Sym!atetic !atway is overstimulated
Color cange H wite" .lue" red H
%8O !reci!itated .y cold" 2O .y emotions
#ifferentiate s!astic #2SBASB , !rimary VS o.structive S=N#ROMB ,secondary
S!asticC 'VR and waveforms normal at room tem!" worse wit cold
O.structiveC a( "oom (em5e"a(u"e 2 ;EE abno"ma+ .GR
#iagnosis of #2SBASBC termal test done only wen o.structive com!onent is e/cluded&
Barly vasosas!m wit tem!erature dro! 0two cuffsC !ro/imal digit cold" distal digit
warm1
Recover ta:es Q 20 min
?ave reactive y!eremia on rewarming
See 'ea:ed !ulse 0suggestive of vasos!asm1
20O of Raynaud9s ave scleroderma"
80O of scleroderma ave Raynaude9s
MC5# H *O
Aterosclerosis H 8O
3uerger H FO
age *%
5reatmentC
Avoid cold" .eta.loc:ers" smo:ing
CC3" al!a .loc:ers" yoim.in el!ful
2n rare cases H consider sym!atectomy
'rognosticate H
o Bvaluate !resence of sym!toms of C5#
o 'erform C5# anti.ody screen
if C5# screen !ositive" !atient may ave !rogession to o.structive !attern
i&e& in tis case" dealing wit early Raynaud9s syndrome NO5 4ust
Raynaud9s disease
o 2f tere are no C5# sym!toms at !resentation
age G0
ris: of C5# is GO at E&E& years
o 2f sym!toms of C5# are !resentC
ris: of C5# is ig 0 u! to *0O 1
62.Connecti*e tissue disorders:
Systemic sclerosis 0a:a scleroderma1
o Strictly s!ea:ing H small vessel VASCUAO'A5?=" NO5 VASCUA252S
o J)T an in'+amma(o"$ &as%u+i(is
Ai:ely due to SMC !roliferation
o Auminal narrowing
o Most commonly C5# associated wit Rayaud9s
o Un:nown etiology
o 6i.rosis of s:in and internal organs
\
Su.ty!es of sclerodermaC
o #iffuseC
10 $ea" su"&i&a+ 40/A0K
'ulm y!ertension
Renal failure
o Aimited scleroderma
CRBS5
10 $ea" su"&i&a+ L0K
Calcinosis" raynaudes" eso!ageal dismotility"
sclredodactyliy" telangectasia
More .enign
Aess eartLlungL:idney !ro.lems
#iagnosisC
Clinical
A3C
o 'ositive ANA
s!ec:led !attern
seen in %*O of !t
NONS'BC262C
see also in SAB , omogenious
o Scl,+0 more s!ecific
o E;R J)RMAL
SAB
o =oung females" .ut all age grou!s are susce!ti.le
o Artlagia" s:in ras" !ericarditis" !leuritis" Klomerulone!ritis
o 'ositive ANA H omogenious !attern
o Raynaud !enomenon is seen in +0O
Reumatoid artritis and S4ogrenC
age G)
o Small vessel vasculitis wit o.literative fi.rosis
Mi/ed C5#C
o Overla! of two C5#
Usually SAB and Scleroderma
'olyarterirtis
Mi/ed .ag
63. Diffirential diagnosis of positi*e A(A:
SAB H omogenious ANA
Sclreroderma H s!ec:led ANA
CRBS5 H anticentromere A3
64.-asculitis:
Tab+e 38/M8 F+assi'i%a(ion o' Gas%u+i(is1
Gesse+ size AJFA JEIAT9GE AJFA .);9T9GE
Aarge 5a:ayasu]s arteritis ,
Kiant cell arteritis ,
Medium Iawasa:i]s disease Curg,Strauss angiitis 0',ANCA1
'olyarteritis nodosa ,
3e^et]s disease ,
#rug a.use vasculitis ,
Small ?enoc,Sc_nlein !ur!ura -egener]s granulomatosis 0C,ANIA1
Bssential cryoglo.ulinemia Microsco!ic !olyangiitis 0',ANIA1
Arteritis of connective tissue
0Scl" SAB" RA" MC5#1
65.&ypes of &akayasu Arteritis:
modified Ueno classification
aortic arc onlyC F0O
descending toracic and a.do aorta H middle aortic syndrome C ))O
involves .ot )& and 2& C G*O
!ulmonary artery involvement PL, ),EC )*O
all to a a!!y total of )E)O
age G2

RuterfordC
most common large vessel arteritis
disease of te young R E0 year olds
.ot stenotic and aneurismal disease
in NA" most common !resentation is u!!er lim. iscemia" closely followed .y CVA&
?5N in EE,88O
o renal a& stenosis" may .e missed unless !ressure in .ot arms is measured
2solated AAA
Aortic regurgitation 0ascending a& dilation1 H 20O
'ulmonary ?5N 0une/!lained dys!nea1
10K o' a%(i&e disease ha&e no"ma+ FR. and E;R
Most often disease is diagnosed at reconstruction
o i&e& not in an active stage
Un:nown etiology" 'an,arteritis" 'atcy involvement
Kranulomatous lesions" .ut no caseation and cavitation
#isease is transmural
o i&e& tere is NO role endarterectomy or !atc angio!lasty H !refer .y!assM
Res!onds to systemic steroids and cytoto/ic drugs
o if in active stage
StagesC
'rodromal !art
2nflammatory
3urned out
Clinical !resentationsC
Stro:e
C?6
?5N
age GE
CR6
Aneurysm
'ulm ?5N
Aortic regurgitation
o Mortality due to uncontrolled y!ertensionC stro:e" C?6
o Can9t follow stages using la.s" need to ave serial imaging&
o Main !atology is stenosisLo.struction" occasionally aneurysmC
o Surgery is contem!lated in .urnt out stage only
o Aong stenosis H
o S!aring ascending aorta 0in %*O of cases1
o carotid
.y!ass to te level of te carotid .ul.
o Renal artery
may consider '5A )
st
for renal a& stenosis
!oor long term results for oter locations
o 2nfrarenal aorta H u! to 0.ut not at1 te level of .ifurcation
May consider toracic aorta ,Q single iliac .y!ass H will re!erfuse
te oter e/tremity via !reserved .ifurcationM
o 2nnominate arteryLsu.clavianC
3y!ass to su.clavianLa/illary artery H
Not for iscemic sym!toms
'rimaly !ur!oseC to .e a.le to diagnose ?5N 0.y arm 3'
measurement1
Com!lications of ?5N is te most im!ortant cause of
mortality in 5a:M
2m!ortantC ma:e sure disease is in .urned out stage .efore .y!assing&
66.7iant cell arteritis:
Blderly affected
'redominantly middle si;ed vessels and aortic involvement
6re>uent involvement of BCA .rances" including o!talmic artery
o 'ainful tem!oral a&
o Retinal iscemia leads to .lindness
o $aw claudication in *0O
Can ave aortic arc involvement only
'olymyalgia reumatica common
Criteria of Am Col ReumatologyC
o Age Q *0 yoa
o Aocali;ed eadace
age GF
o 5em! artery tenderness on e/am
o BSR Q *0
o 5A .io!sy !ositive for KCA
U! to 20O of !ts ave normal ./
F0O negative wit aortic arc syndrome only
67.,e"cet disease diagnosis:
o Systemic vasculitis" un:nown origin
o ?allmar:C OralLgenital ulcers and recurrent uveitis
o NO la. mar:ers
#iagnostic criteriaC
o Ma4or H oral ulcers
o MinorC need 2
Kenital lesionsC
recurrent ulcer
Bye lesionsC
AntL!ost uveitisLretinal vasculo!aty H seen in 80O
o May lead to .lindness
S:in lesionsC
erytema nodosum" !seudofolliculitis" acne"
'atergyC
o clear !ustule F8 !ost s:in !uncture
OterC
venous trom.osis 0UB" AB" SVC" 2VC1
o MOS5 COMMON VBSSBA 'A5?OAOK=
*0O of !ts
o #ue toC
o 'rotrom.ic state
o Bndotelial in4ury
o #efective fi.rinolysis
Arterial !atologyC
o SBCON# MOS5 COMMON VBSSBA 'A5?
U! to EFO of !ts
o aneurysms ,
more common tan occlusive
AAA Q!ulm Qfem Q!o!Q.racial Qiliac
Leading %ause o' dea(h in <D 2 RH.THRE
2ntracranial aneurysms descri.ed
o occlusive arterial disease AB and UB
.etter !rognosis
age G*
increased ris: of .y!ass trom.osis
!ericardis E,GO
Artritis
K2 ulcers
CNS 0sei;uresLmeningitisL!alsy1"
Klomerulone!ritis , +&*O
SummaryC
o sore mout AN# sore eyeL!enisLs:inLoter
o !atergy
o die from AAA ru!ture
o no la. test" clinical diagnosis
o more venous rater tan arterial !ro.lems
5reatmentC
o 2mmunosu!!ressive for o!talmicLneurologicLvascular com!lications
o No serologic mar:ers to follow
o Aarge dose steroids for vascular" may need second agent
o Cyclos!orine
o 6or oralLgenital ulcers H 5?AA2#OM2#B
o if tis drug is given for females" consider doing ysterectomy or 5A first
68.O&HR #id 3 s!all *essel *asculitis:
o 'AN H !olyarteritis nodosa
Systemic necroti;ing vasculitis
AneurysmsLru!turesLtrom.osis in any organ
Common !resentationC
a.do !ain in young adults
o Mesenteric aneurismal involvement
BSR u!" .ut ANCA is negative
Angio H multi!le visceral aneurysms
?e! 3 antigen !ositive in E0O" associated wit ?2V
o Iawasa:iC
Affects infantsLcildren R *yoa
20,E0O , coronary aneurysm
OterC !ericardial effusion" MR" C?6
Multi!le oter 0aorta" viscera1 aneurysms wit age
o Curg,Strauss H tree stages
i1 Allergic !ase H sinusitis" rinitis" Astma
ii1 Bosino!ilia wit eosino!ilic infiltrates
!neumonia" gastroenteritis" neuro!aty
age GG
iii1 Vasculitis
Mc site Hcoronary" .ut any vessel can .e involved
o .,ANCA !ositive
o More .ro/imal vessels involved
69. S!all *essel arteritis:
o -egener9s
Necroti;ing granulomatous vasc
Classic lesionsC Iidney and U!!er res! tract
'resentationC digital iscemia and nail fold infarct
F/AJFA 5osi(i&e in N0K in a%(i&e disease
o Microsco!ic !olyangiitis
$ust vasculitis of small vessesl" ',ANCA !ositive
70. S!all *essel pat"ology leading to digital is"c"e!ia: DD
ANCA !ositiveC
o Microsco!ic !olyangiitis
o -egener9s
ANCA negativeC
o C5#
o Cryoglo.ulinemia
5raumaC
o Vi.ration
o 6rost
em.olic
71.Arteritis associated wit" aneurys! for!ation:
o 5a:ayasu
o 'AN
o Iawasa:i
o 3ecet
o #rug induced
Oter -<- conditions tat can ave AAAC Blers,#anlos" Marfan" 5urner" 'CI#
WEIRD & WONDERFUL
72.,uerger5s disease diagnostic criteria:
o 'redominantly male" .ut may see in female
age G+
2n Nort America" u! to )*,E0O of !ts are -OMBN
o Onset R F* yoa
o Smo:ing /
o 2nfra!o!litealLinfra.racial arterial involvement leading to iscemia
documented clinically 0R'" ulcer1 and o.4ectively
o No oter R6 for aterosclerosis 0#M" tn" li!ids1
o Bco and angio e/clusion ofC
!ro/imal em.olism 0cardiac" 5OS" aneu" arc" atero1
trauma
local lesions 0adv cyst d" !o! entra!ment1
o Aa. test e/clusion of autoimmune" C5#" #M" myelo!roliferative #O
o Oter featuresC
Migratory !le.itis" Raynaud9s" inste! claudication
BtiologyC no one :nows" smo:ing" genetics" y!ercoag and endotelial dysfunction"
immunologic mecanism
?istologicallyC
trom.us is inflammatory
inner elastic lamina is spared
no acute !ase reactants 0unless acute infarction of lim.1
mar:ers of immune,activation are a.sent
discontinuous lesions
SummaryC
distal arterial disease
-25? smo:ing
-25?OU5 #M" li!id" ?5N" em.olus" C5#" myelo
5reatmentC
Sto! smo:ing" no nicotin !atcesLgum" !ain management" ASA" CaC3"
ilo!rost" de.ride" .y!ass or am!utate if necessary
'ain control H s!inal cord stimulator
Am!utation rateC
in smo:ers H FEO"
e/,smo:ers H GO
73.Angiograp"ic features of ,uerger5s disease:
o Normal !ro/imal a&
i&e& no ateroscelrosis
o 2nvolvement of vessels distal to .racial and !o! artery
Segmental involvement 0normal intermingles wit a.normal1
Severity increases distally
age G8
o Collaterali;ation in te vasa,vasorum H cor:,screw collaterals
o No source of em.olism
74.0nco!!on causes of aneurys!s
Arteritis 0see a.ove1
MarfanC
Must ave clinical findings" not genetically documented classic
63N) mutations alone
2*O of te !atients ave new mutation
#efective elastic tissue
#isease continuum
5all tin" long armLlegs" ArmLeigt Q )&0*
'ectus carinatumLe/cavatum
Aortic dilation
Ascending involved in 80O
33 !ro!yla/is essential
Re!lace ascending aortaLsinus wen Q* cm
2n !regnancy H use 33"
dilation to Q Fcm is ig ris: for ru!ture
Blers,#anlosC
Collagen syntesis !ro.lem
S:in y!erelasticity" fragility" 4oint y!ermo.ility
)) ty!es H diverse clinical !resentation
5y!e G as vascular relevance
Only FO of all ty!es
ReducedLa.normal ty!e F collagen
o 5in s:in" easy .ruises"
o 7Alien from te flying saucer8 face 0tin li!s"
!rominent eyes" narrow nose" no sc fat1
Most relevant !resentation is 'erforationC
o Vessels
o Uterus H )),2*O of !regnancies in tese !ts
o Colon 0sigmoid1
MC cause of deat H arterial ru!ture
Multi!le aneurysms" only )GO aware of diagnosis !rior to
ru!ture
o Unusual com!artement syndroms 0.uttoc: wit
gluteal a& ru!ture1
2n emergency" ligation !refera.le to .y!ass
Bndo may ave role
Avoid s!orts
5urner" !olycystic :idney associtated wit 5AA
age G%
75.&ypes of collagen:
o ) HMC" %0O" tendons" ligs" .ones
o 2 H yaline cartilage
o E H vascular structures and colon
o F < * H .asement mem.ranes and C5 matri/
76. 1eatures of pseudoxant"o!a elasticu!?
May !resent as young male wit retinal emorrage" coronary artery disease" and .ilateral
leg claudications&
'seudo/antoma elasticumC
o C5# tat causes elastin degeneration ,Q calcification
o 'redis!oses to Barly AKRBSS2VB diffuse aterosclerosis
o +0O of !atients are R E* yoa
o S:in" eye" cardiovascular system
o Jantomas along nec:Lgroin fle/ion lines 0cic:en s:in1
o S!ontaneous retinal emorrages ,Q .lindness
CA#
o #on9t use A2MALR2MA" only KSVM
Stro:e
Soft tissue calcification 0el.ow" i!1
o #d trauma" scleroderma" y!er '5?
Aggressive aterosclerosis R6 modification&
77.Pat"ology of radiation *asculitis:
o Causes accelerated aterosclerosis
o 2n4ury to vasa,vasorum
o 2scemic necrosis of vessel wall
o 6i.rosis of internal elastic lamina
o 5ic:ening of adventitia
o Aong smoot ta!ering stenosis
78.Clinical syndro!es associated wit" cystic !edial necrosis:
o Marfan
o Blers,#anlos
o Some ty!es of Neurofi.romatosis
o All muco!olysaccaridoses
age +0
?yaline degeneration of media" re!lacement wit mucoid .aso!ilc su.stance&
'resents asC
)& AorticLcarotid dissection
2& #isseminated arterial ru!ture
E& S!ontaneous ru!ture
79.-isceral Splanc"nic Artery aneursy!s:
S!lenic 0G0O1"
e!atic 020O1"
SMA 0GO1"
Celiac 0F O1
KastricLgasroe!i!loic 0FO1"
intestinalL!ancreatic 02O1&
i&e& After celiac" go cloc:wiseC gastric" gastroe!i!loic" intestinal" !ancreatic
80.Classification of splenic a@ aneurys!s:
Usually saccular" at .ifurcations" multi!le in 20O&
o 5rue
Associated wit arterial fi.rodys!lasia 06M#1
Associate wit !ortal ?5NLs!lenomegaly
'regnancy induced 0multi!arity1
rLo 'AN" Iawasa:i" Blers,#anlos
o 6alse
'ancreatitis induced
5rauma
o 'enetrating
o 3lunt
infected
81.Indications and treat!ent for splenic artery aneurys!
repair:
o Q2 cm in good ris: !ts" some say Q E cm
o 'regnant or 'otentially !regnant !t
o Sym!tomatic
Ru!ture , R 2O
o 2f !regnant H %*O of aneurysm diagnosed during !regnancy are ru!tured
o #ou.le ru!ture H first in lesser sac:" ten !eriotoneal cavity
Re!airC
age +)
ligate or s!lenectomy
6or !ro/imalC sim!le ligationLe/clusion no reconstruction
MidC usually false aneurysms associated wit !ancreatitis
o ligation"
o ten o!en aneurysm"
o ligate .rancesLartery form witin
#istal H s!lenectomy
82.Hepatic a@ aneurys!:
o 2 times more common in males
o 2*O medial degeneration H MC cause according to Ruterford Com!anio n
2n E* O aterosclerosis is seen H .ut tis is co,incidental
o 22O !seudoaneurysm
trauma
o )*O mycotic due to 2V drug a.use
o Oter causesC
'AN
5rauma"
am!etamines
o 80O e/trae!atic" 20O e!atic
o 20O ru!ture rate
o May ligate if in C?A"
o e!atic artery .rances involvement may re>uire reconstruction&
o ?e!atic locali;ationC
Bm.olectomy vs lo.ectomy
83.S#A/ celiac/ gastroepiploic aneurys!:
o SMA
G0O mycotic
Current !a!ers says less
Non,emolytic stre!
More common in younger
20O aterosclerosis
#rugs H cocain and ergot
Ru!ture can .e seen in u! to F0O
#o not stent teseM
o Celiac aneurysm H
mostly degenerative 0i&e& secondary to aterosclerosis1
ru!ture )EO
o Kastroe!i!loic
age +2
2f see multi!le onces" !articularly in K#A distri.ution H loo: for
ig flow situation
%0O !resent wit ru!ture
+0O into K2
E0O intra!eritoneal
AigateLem.olise all
84. Renal a@ aneurys!:
#egenerative
o 6M#
o Vasculitits
o 'AN
o 3ecet
%0O e/trarenal
EO ru!ture
Re!air inC
o 2m!regnata.le females
o Sym!tomatic
?tn
?ematuria
'ain
?ydrone!rosis
o QE,F cm in asym!tomatic
85.Co!plex regional pain syndro!e :
A:a causalgiaM
o 5is syndrome is %om5+e7
involves autonomic" vascular" motor" cutaneous" inflammatory
canges
o it is "egiona+
s/s and findings are .eyond te original region of in4ury
o it is very 5ainful
severity usually out of !ro!ortion to te initiating event
o 5y!e ) H due to inciting no/ious event
5rauma 0MC1
Non,traumatic
o 'ost !rolonged .ed rest
o 'ost M2LCVALneo!lasms
Soulder,and syndrome
2dio!atic
o 5y!e 2 H due to nerve in4ury
age +E
flare,Qdystro!y,Qatro!y
o Stage 2 acuteC
?ot<sweaty" swollen" .urning y!er,!ain
5/C !ysical tera!y main stay& 2f can9t do tis .ecause of !ain" try
S=MA5?B52C 3AOCI H may .e long lasting
steroids" local nerve .loc:" 5BNS 0transcutaneous electric nerve
stimulator1
o Stage 22 dystro!icC
cold" mottled" osteo!oroticL.rittle nails" continuous !ain
5/C !ysio .ut may try sym!atectomy
UNABSS tere is dramatic res!onse to sym!atetic 3AOCI
first" do not go for sym!atectomy
5BNs" steroids
o Stage 222 atro!icC
atro!ic" contracted" !ain elsewere
5/C sym!atectomy less successful" !ysio" 5BNs" antide!ressant
Most el!ful confirming diagnostic feature of CR'S is RBS'ONSB to
sym!atetic .loc:& Oter tests H a.normal sweating" termogra!y&
86.&ypes of 1#D:
CauseC
Bstrogen effect
Mural iscemia 0lac: of .rances1
Re!etitive trauma 0.ending and stretcing1
5in: of $a..a te ?utt H
toug fi.rous core"
toug fi.rousLy!er!lentiful middle"
malignantLdys!lastic e/teriorM
o 2nside H intimal 623RO !lasia H *O
MUf
o Middle H
medial 623RO !lasia H 8*O
most common
medial ?='BR !lasia H )O
rare
o !erimedial #=S'AAS2A H )0O
Most common is medial fi.ro!lasia
age +F
String of .eads aneurismal dilatation
Midd+e (o dis(a+ "ena+ a8 a''e%(ed
.Ll in **O
R sided more common tan A
?istology H
o fi.rous connective tissue re!laces Smoot Muscle Cells
)0O ave .erry aneurysms in ead
o 80O solitary
o 20O multi!le
87. #ost co!!on arteries affected wit" 1#DA
o Renal artery
o Carotid arteries
0&FO of all carotid angios sow tis" G*O .ilateral
o B/ternal 2liac arteries
5reatment of RBNAA 6M#C '5AM
5reatment of CARO52# 6M#C
Standard H o!en gradual intraluminal dilation& 2 mm to G mm to te .ase of te
s:ull" .ac: flus de.ree from 2CA&
Oter o!tionC '5A" .ut in a review of )+0 cases *O ad neuro deficit& Clinical
Scenarios in Vasc Surgery do not recommend tis as a
88. Portal "ypertension and .leed:
5reat definitively after first .leeding e!isode
o +0O will re.leed wit +*O mortality rate
3anding and o.servation is contraindicated if !t leaves far away
o #oes not wor: well for gastric vari/
3eta .loc:ers reduce re.leed .y *0O
52'S H %0O success" .ut 2*O !ortosystemic ence!alo!aty
89.Indication to treat *asc !alfo!ations:
o a.solute
local effectsC
distal stealLiscemia
non,ealing ulcer
.leeding
Aeg lengt discre!ancy
Aneurismal degeneration
systemic effectsC
age +*
C?6
#2C
o RelativeC
Cosmesis
#isa.ling 'ain
Aimiting claudication
Com!ression of structures
90. Ha!.urg classification of *ascular !alfor!ations:
5umors
o A.normal endotelial turnover
o MC infantile emangioma
Starts at .irt .ut usually seen at 2L*2
Krows wit cild" regresses wit age
%0O gone .y % yoa
Malformations
o Normal endotelial turnover
91.4lippel)&renaunay:
o Slow flow AVM
o soft tissueLs:eletal y!ertro!y
o Ca!illary malformation
age +G
o Aym!atic y!er!lasia
o Anomalous lateral leg vein of Servelle
o OterC ematuria" ematoce;ia" consti!ation" .ladder outlet o.struction
'ar:es we..er H same !lus Clinically 6AS5 flow AVM& I5 as tem too .ut it is micro
and not clinically significantM
6acial V),V2 ca!illary malformation H sus!ect intracranialLle!tomeningealLori.tital vasc
malformation& VE carries no suc !ros!ect&
92. Sclerot"erapy:
6or varicosities H etanolamine" !olidocanol" NO5 etanol
VM H S5#" etanol&
93. -ascular tu!ors:
Vascular leyomyosarcomaC
o Most commonly found in 2VC" not arteries& #ismal survival H discovered
wit mets&
MC tumor to grow into 2VC H RCC
MC tumore to o.literate 2VC in R' , sarcoma
94.Congenital defects and sy!pto!s:
#ou.le aortic arc H
o vasc ring around tracLeso!agus" ,Q dys!agiaLdys!nea
#uctus arteriosus H
o Mos( %ommon %ongeni(a+ abno"ma+i($
o sunt from aorta into !ulm artery ,Q !ulm ?5N
R a..erant su.clavian a& H
o 5a:es off distal to Aeft su.clavian artery" .eind 5racLBso or .etween
tracea and eso!agus" causing to dys!agia lusoria < dys!nea
o May ave aneurismal dilatation at origin 0:nown as Iommeroll
diverticulum1
'ersistent sciatic artery ,
o !rone to aneurismal dilation
3ovine arc H 2nnominate and A CCA are 4oinedC
o 5rue common trun: seen in 8O" common origin only is )GO
A verte.ral off aortic arcC 8O
95. Persistent sciatic artery:
o 'ersistence of fetal circulation
o Off internal iliac" down to !o!liteal along sciatic n"
age ++
diminutive S6A !resent" no femoral !ulse
o 'rone to degeneration
o 'resents wit .uttoc: mass" emo.li;aiton" sciatic nerve !ressure"
em.oli;ation
o +0O unilateral
o 'o! !ulse .ut no femoral !ulse
o Aneurysm in F0O
at greater trocanter
o Re!air aneurysm vs ligation !lus fem,!o! .y!ass
96. A..erant Rt@ Su.cla*ian artery:
o 0&*,)O of !eo!le
o Caused .y involution of R F
t
aortic arc&
o 2nstead" R su.clavian artery forms from +
t
intersegmental artery dis(a+ to A
su.clavian artery
o 'asses usually !osterior to eso!agus"
.ut can !ass .tw eso!agus 80O" trac )*O" anterior to trac *O
o Can result in dys!agia lusoria
o NoteC
dys!agia lusoria can .e caused .y !ersistent a..erant A SCA
originating from R sided arc !ressing on eso!agus& RARB
o Iommerell9s diverticulum H remnant of te F
t
aortic arc at te aorta
o According to Ruterford te/t" re!air only for
sym!toms or
QF cm in asym!tomatic !t
o Re!airC
endo e/clusion !lus e/tratoracic reconstruction 0y.rid1
.ranced endo graft
o 2f Iommerell is seen H wic is most of te cases
need eiter
.ranced endo"
aortic arc re!air
o 'ts will also ave .ovine arc" A verte.ral ta:ing off aortic arc" R sided
toracic duct and anomalous R recurrent laryngeal nerve H direct course off
vagus&
97. %"at is re2uired to "a*e a nor!al erection?
o NervesC
Nervi erigentes H sym!atetic 5)2,AF and !arasym!atetic
S2,SF
o 'arasym!atetic H
age +8
cause vasodilation" leads to tumescence
o Sym!atetic H
Regulates e4aculation
nerves form !le/us at te root of 2MA and aortic .ifurcation&
Nerves course anterior to A common iliac artery
o Careful wit dissection
o ArteriesC
2nternal !udendal a& H need tis as a re>uirement for
successful erection
Mecanism of erectionC
2ncreased arterial inflow into cor!oreal .odies
Normally .lood in cavernous .ody is desaturated&
-it .lood flow" o/ygenation of cavernosal nerves and endotelium !roduces
more NO
o i&e& ?y!o/ia decreases NO
NO stimulates cKM' !roduction
o !romotes SMC rela/ation
2nfilling of te cavernous .ody and SMC rela/ationC
o distends !enis and occludes venous outflow&
o 'ressure goes from )* mm to %0 mm
Bventually" at ma/imum u!ward !osture" cavernous artery 0center1 flow ceases&
o Ma/imum !ressure of )20 is reaced&
o -it reduced flow" desaturation ta:es !lace ,Q te ting goes flaccidM
98. rectile disorder:
o 'ersistentLre!eated ina.ility to acieve erection to !erform an intercourse
o At least E monts
o No e4aculatory disorder
Fauses o' d$s'un%(ion-
Most common underlying mecanism H failure of cavernosal smoot muscle rela/ation&
Vascular 0macro AN# micro circulation1
Bndocrine H E,FO
Meta.olic
Neurogenic
'sycologic
#rug induced H
o Antiy!ertensive
Note ACB2 are s!aring
age +%
5o test for vascular insufficiency" try 'KB) in4ection H if ade>uate errection is
acieved" ten vascular su!!ly is o:&
Vascular causesC
'oor arterial inflow
A2O#
Steal to e/ternal iliac artery
Occlusive disease of !enile arteries
Ateroem.olic occlusions
3lood !ressure effect on arteries 03eta .loc:ers1
Venous lea:s at te cavernosum .odies
5rauma to tunica al.ugenea
Congenital lea:age
cavernosum is messed u!
o 6i.rosis 0!ost !ria!ism1
o 'eyronie9s H deformity invading into SMC
o Refractory smoot muscle H does not res!ond to stimulation
?ormonal 0!rolactin" low testosterone".lood !ressure med1
Meta.olic 0#M" uremia1
-or: u!C
'rolactin" testosterone" glucose" 'SA
'KB) in4ection
T"$ o"a+ d"ugs 'i"s(, ten intracavernous in4ection" ten vacuume constrictors&
o Sildenafil is NO5 recommended for women
26 tese fail" ten invasive testing H angioLvenogram& 2f tese fail wit additional
trial of #rugsL2C2LVC H ten try !rostesis&
EMBOLISM, THROMBOSIS & LIMB ISCHEMIA IN GENERAL
99. Causes of arterial occlusion in general:
em.olism
trom.osis
!re,e/isting occlusive disease
ru!tured !la>ue
!oor inflowC
low flow state
sluggis .lood flow leading to trom.osis
.y!assLconduit occlusion
age 80
disease
mecanical !ro.lem
outflow occlusion
.lood flow .ac:ed u! leading to trom.osis
y!ercoagula.le state
trom.osis in normal vessels
congenital" malignancy" !ost,o!" trauma
trauma < dissection
disru!tion of normal vessel
100. #ost co!!on sources of e!.olis!:
eart
o ASC eart diseaseC
M2"
Arrytmias
o Atrial my/oma
o Valvular eart diseaseC
R6"
#egenerative"
Congenital"
3acterial"
'rostetic
artery to arteryC
aneurysm"
aterosclerotic !la>ue
2dio!atic
'arado/ical
o 'atent foramen ovale H u! to 2*O of !o!ulation ave it
101. #ost co!!on sites of e!.olisation:
o femoral H MC H E*,*0O
o !o!liteal H 2
nd
MC H 20,E0O
o cere.ral H 20O
o u!!er e/teremity H )*O
o visceral H )0O
#uring em.olectomy" longitudinal arteriotomy is recommended H if em.olectomy fails"
may do .y!ass& Use A2R for `) and 2 6ogarty H air is more res!onsive to cange in
diameter tan saline H less cance of endotelial in4ury&
Aivido Reticularis H most common cutaneous sign of microateroem.oism 0tras foot and
tras can1& Sym!tom wise" can see fatigue and weigt loss if ateroem.olism is
dissiminated&
age 8)
102. At"eroe!.olic Renal falure: i@e@ parenc"i!al causes?
##
o A5N due to contrast ne!ro!aty
o A5N due to iscemia
o Bmtolism
Arterio,arterial
Cardiac em.olism
Clot
Atrial my/oma
S3B" A3B
o -eird and wonderfulC
Necroti;ing vasculitis
5rom.otic trom.ocyto!enic !ur!ura
Anti!os!oli!id anti.ody
Multi!le myeloma
Aa. H unel!ful in general
o Bosino!ilia in ateroem.olism
o BSR" CR' u!
o UA H see urine sediment in A5N 0dirty .rown cast1
2m!ortant to distinguis contrast vs iscemiaC
o Consider time,frameC
Contrast ne!ro!atyLA5N H
renal failure witin +2
renal failure usually recovers
no"ma+ b+ood 5"essu"e8 i8e no HTJ
Ateroem.olism H
rise in creatinine may .e delayed .y a wee:
"e'"a%(o"$ h$5e"(ension
renal failure mostly non,refersi.le
!oor outcomeC
) year mortality GF,8)O" due to cardiac" CVA" K2 iscemia
5reatment and !reventionC
)& Sta.ili;e !la>ueC
Statins
Anti!latelets
ACB2
'latelet infusionsD
2lo!rostD 0see Ruterford" does wor: in some studies1
2& Surgical control of source
a& Only if medical tera!y failed
age 82
.& O!en surgery vs endo
ArcLtoracic aorta !la>ue H
if Q*mm tic:C
o EEO annual ris: of vascular events vs +O in control&
Overall" non,calcified < at least F mm !la>ue are a ris: factor for
ateroem.olism
o 2t is suggested to start warfarin on tese !ts 0ACC'" 200)1
3etter ten ASA alone
Com.ined wit statin
Surgery
o O!tion for minority only
o only on igly selected !ts" low OR ris:" ave multi!le documented
em.olic events des!ite medical tera!y
see aorta !art of oral in training e/amsM&
103. Causes of arterial t"ro!.osis:
o Aterosclerosis H e/!osed ru!tured !la>ue
o Aow flowC
C?6
cardiogenic soc:
y!otension
o vascular graft
trom.ogenic
disease !rogression in graft 0Aterosclerosis1
initimal y!er!lasia
mecanicalC :in:" valve
o traumaC
intimal fla! vs s!asm vs com!ression
!enetrating
.lunt
drug a.use
o y!ercoagula.le state 0see .elow1
o outflow o.structionC
arterial H disease !rogression" dissection
venous H com!artment" !legmasia
104. tiology of post op acute $eg isc"e!ia post AAA repair:
age 8E
Most common RBCOKN2YA3AB causeC
Raised intimal fla! 2*O
Iin:ing 8O
'ost o! y!otension 8O
Causes e/!andedC
o 5rom.osisC
lim. of #acron graft
diseased iliac" C6A" S6A" !rofunda
!o! a& aneurysm
o em.oliC
trom.us
from te eart
from !ro/imal vessel wit inade>uate e!arini;ation
dislodged !l>ue 0ateroem.oli1
5o !reventC
)& ?e!arini;e !t !rior to clam!ing
2& 3ac: .leed iliacs !rior to !ro/imal clam! removal
E& 6lus graft !rior to distal clam! removal
F& Ai.eral use of 6ogarty
*& #o not leave OR witout cec:ing feet first
G& #o not clam! C2A
a& Clam! 2AA and B2A instead" less cance will tras clot in C2A downstream
ManagementC
)& 're! .ot groins
2& B/!lore inde/ groinC
a& Cec: inflow
.& Cec: anastomosis
c& Cec: S6AL!rofunda
E& Consider trom.ectomy vs fem,fem vs a/fem
F& Consider !rofundo!lasty
*& Monitor ?g and consider fasciotomies if Q G iscemia
105. Infrainguinal graft t"ro!.osis:
o Barly failure rate *,)0O witin E0 days
o 3ad !rognosis even in successfully trom.ectemi;ed graftsC
At ) year H *0O am!" 2*O R'" )*O died
o A!!roacC
Confirm trom.osis
age 8F
Minimi;e clot !ro!agation 0AC1
Assess neurologic and motor status
Review indication for .y!ass 02C vs R'Lulcer1
#ecide if need to intervene at all
#ecide if graft can .e salvaged
See wat conduits are availa.le
CauseC
Kraft trom.ogenicity
y!ercoag state
!oor run off
!oor inflow
undetected asc disease
!oor cardiac out!ut
o deydration
o cardiac decom!ensation
in A0K o' %ases 'ai+u"e is due (o (he %ondui( 5"ob+ems
80K o' (hese is %o""e%(ab+e
Te%hni%a+ e""o"s "es5onsib+e 'o" 4/3MK g"a'( 'ai+u"es
A( e75+o"a(ion, M0K o' g"a'(s ha&e no a55a"en( 5"ob+ems8
2f decided to salvage" decide surgery vs trom.olysis&
Results of .ot are !oor&
o lysis won9t el! in !ts wit #M < recent graft&
'refer surgery for most
Outcome is .etter if tecnical !ro.lem 0cus!" twist or stensis1 is
identified&
See notes on 5rom.olysis
106.Isc"e!ia 3 reperfusion effects on organs:
2scemia de!letes intracellular energy sourceC
o switc to anaero.ic meta.olism
o generation of to/ic radicals&
o Adesion molecules generated H inflammatory cells come in
o 2n te endC
Organel and cell mem.ranes are disru!ted as ionic !um!s sto!
2nflu/ of CaPP causes cell deat and fluid e/travasation
5ransudation of fluid cauase edema and ca!illary occlusion
o Re!erfusion effects H
wases out cell deat de.rie into circulation H
age 8*
ig I" urea" acid" myoglo.in
o arrytmias and renal failure
.rings in o/ygen to damaged tissues
o/ygen free radicals form&
radicals overwelm damaged antio/idant system H
cause furter damage to ealty" surviving mem.ranes H
furter cell damage&
o S2RS and organ dysfunction
o No reflow !enomenon wit re!erfusionC
Mini,com!artment syndrome
No o.vious o.struction
No flow troug microca!illary .ed
Unclear etiology&
#escri.ed in coronary literature 07.ro:en eart syndrome81
Several causes seenC
s!asm of te microcirculation"
local !latelet activation"
microvessel em.oli;ation
tissue edema
COAGULATION & ANTICOAGULATION
107. Su!!ari>e coagulation cascade:
B/trinsic H
o tissue factor activates V22
o V22a activates small amount of factor J AJD 'a%(o" 9O8
5is re!resents an im!ortant feature H CROSS tal: to 2ntrinsic
!atway
V22a is >uic:ly inactivated .y 5issue 6actor 'atway 2ni.itor
o Ja 0initially activated .y V22a1 activates small amount of V222 and V
o activated factors 2J 0from V22a1" V222 0from Ja1" and !lus Ca
2P
form tenase
com!le/ on te surface of !!t
*0 times more active tan V22a&
Massive amounts of Ja are formed
o Ja" Va" Ca
2P
and !!t activate trom.in tat converts fi.rinogen to fi.rin&
2ntrinsicC J22,QJ2,Q2JM
Common !atway H J activates 22" 22 creates fi.rin
age 8G
3ut te most im!ortant source of activated factor J is from tenase action&
6i.in is sta.ili;ed .y factor J222
.+asmin inhibi(o"s- 5"o%oagu+an(s:
'lasminogen Activator 2ni.itor H ) 0'A2,)1
o inactivates t'AM
o e/cess causes arterial AN# venous y!ercoagula.le state
Al!a 2 anti!lasmin
o 2ni.ited .y de/tran F0
An(i%oagu+a(ion a"m-
'lasmin H .rea:s down fi.rin
o 2ni.ited .y 'A2,) and al!a2,anti!lasmin
Antitrom.in 222 H
o Always active
o Action is am!lified .y te !resence of ?e!arin
o Most sensitive en;ymes to e!,A5222 is factor 22
Also wor:s vs 2J" J" J2"
'rorein C , Q .inds trom.in and ten trom.omodulin&
o 5is activates 'nC and" togeter wit !n S" .loc:s factor V and V222&
6actor V222 is needed for activation of factor J
6actor V is needed for activation of factor 22
maPo" an(i%oagu+an(
"esis(an%e o' 'a%(o" G (o A.F is MF %ause o' H$5e"%oagu+ab+e
s(a(e
5rom.omodulin H
age 8+
o .inds trom.in inactivating it&
o it accelerates activation of !rotein C tousand fold&
t'A H activator of !lasminogen" secreated .y endotelium
5issue !atway !atway ini.itor 05''21 , anticoagulant
o 'rotein tat inactivates V22a and Ja
o Most of it is .ound .y endotelium and can .e released .y e!arin
o ?as anti,inflammatory !ro!erties
'rostocyclin H
o generates cAM' H reduces !latelet aggregation
108. How does Dextran B: work?
o 'olysaccaride
o 2ncreases electronegativity of R3C" !lt" w.c" reduces aggregation
o 2ni.its al!a,2 anti!lasmin
o Reduces factor V222,V- activity
o #ecreases viscocity
age 88
o +0O eliminated witin 2F 0urine1
o Com!licationsC
May aggravate renal failure 0diuretic1
Ana!yla/is
'ulm edema
Cere.ral edema
109.%arfarin: !ec"anis! of action and co!plications:
o 2nterfers wit utili;ation of vit I .y te liver during syntesis of J" 2J" V22"
22 0)%+21&
o Can9t syntesi;e car.o/yglutamyl residues for CaPP .inding
o 'roduced factors are antigenically similar .ut ave a.normal CaPP .inding
o -arfarin,induced s:in necrosis
#ermal gangrene of te .reast" tig or .uttoc:s
Rare
#ue to transient y!ercoag state 0!n C<S syntesis su!!ression1
Need to .ridge warfarin wit e!arin
o 3leeding 0*O !er year1
110.Contraindications to warfarin t"erapy:
Fon("aindi%a(ion .e"%en( a''e%(ed
Uncontrolled y!ertension 0Q)80L)00 mm?g1 )F&0
6re>uent falls or .lac:outs )E&2
2na.ility to com!ly wit treatment %&8
#aily use of NSA2#s %&2
K2 or urinary .leeding in last si/ monts )&0
B/clusion criteria used in te ma4or intervention trials of anticoagulation for !atients wit
atrial fi.rillation
)& 3leeding disorder or a.normal coagulation at .aseline
2& Uncontrolled y!ertension 0Q )80L)00 mm?g1
E& Active .leeding
F& ?aemorragic retino!aty
*& ?istory of intracranial aemorrage
G& Use of non,steroidal anti,inflammatory drugs
+& Cronic alcool a.use
8& Ris: of gastrointestinal .leeding 0active !e!tic ulcer disease" !ositive faecal occult
.lood testing" :nown oeso!ageal varices1
%& 'lanned surgery or invasive !rocedure
)0& 'regnancy or .reastfeeding
age 8%
))& 'syciatric disorder or dementia
)2& B/!ected !oor com!liance
)E& Aimited life e/!ectancy
)F& Significant renal dysfunction 0creatinine Q 0&2* mmolLA1
)*& 'latelet count R )00 / )0%LA
)G& OterC Recent stro:e or transient iscaemic attac: 0!revious two years1
'atients were also e/cluded if tey refused to !artici!ate or if teir doctor
considered te ris: of anticoagulation was too great&
?armC.enefit analysis in !rescri.ing warfarinC
The "is= o' maPo" b+eeding in 5a(ien( ,i(h AD ("ea(ed ,i(h ,a"'a"in-
o 1/4K 5e" $ea",
o ,i(h an in("a%"ania+ b+eeding "a(e o' 083/08MK 5e" $ea"&
o 5e fatality rate mirrored te intracranial .leeding rate&
2n o.servational studies of am.ulatory !atients te ris: of ma4or .leeding is F,%O
!er annum&
Ma4or determinants of warfarin,induced .leedingC
o intensity of anticoagulation"
o !atient caracteristics"
o te concomitant use of drugs tat interfere wit aemostasis
o te lengt of tera!y
Intensity of anticoagulation and duration of therapy
5e ris: of .leeding increases wen 2NR e/ceeds F&0&
2NR Q F&0 te most im!ortant ris: factor for intracranial aemorrage"
inde!endent of te indication for warfarin&
The "is= o' maPo" b+eeding-
o g"ea(es( in (he 'i"s( mon(h o' (he"a5$ 6QK#
o de%"eases ,i(h (ime (o 088K 5e" mon(h 'o" (he "emainde" o' (he 'i"s(
$ea" and (o 08QK 5e" mon(h (he"ea'(e"8
A6 and ageC
D"amingham s(ud$- (he in%iden%e o' s("o=e due (o AD in%"eased ,i(h age-
o 18MK 'o" M0/MN $ea"s
o 3Q8MK 'o" (hose aged 80/8N $ea"s8
5e !revalence of A6 in !ts 80 years old is)0O&
Advanced age is not itself a contraindication to warfarin&
Studies A6 su!!ort te ongoing .enefit of anticoagulation wit increasing age&
age %0
Wa"'a"in (he"a5$ "edu%es (he "is= o' is%haemi% s("o=e in 5a(ien(s ,i(h non/
"heuma(i% AD '"om L84K (o 38QK 5e" $ea"8
Age is" owever" a R6 for more unsta.le !rotrom.in time results&
o 6or every )0,year increase in age tere is a )*O increase in te ris: of
anticoagulation aving to .e sus!ended .ecause of a raised 2NR&
tt!CLLwww&australian!rescri.er&comLmaga;ineL2+LFL88L%2L`t)
111.%"at drugs affect warfarin:
o .o(en(ia(eaugmen(
Allo!urinol
Aminoglycoside
Amiodarone
Oral y!oglycemics
Acetomeno!en
Ci!ro
Cimetidine
Brytromycin
6lucona;ole
2sonia;ide
Metronida;ole
Ome!rasole
'enytoine
'ro!ranalol
5etracycline
Alcool in liver disease
Remembe" (hese- h$5og+$%emi%, Aminog+$oside, %i5"o, me("onidazo+e, ome"azo+e
AHIMEJT
o 9nhibi(-
Anti,istamines
A;atio!rine
3ar.iturates
Car.ama;e!ine
aldol
Cyclos!orine
s!ironolactone
Rifam!in
Sucralfate
Vit I
Remembe" (hese- Ha+do+, s5i"ono+a%(one, %$%+os5o"in, ba"bi(u"a(es 9JH9<9T
C:@ Heparin *s $#%H:
?e!arinC F000,F0"000 #a"
o !olysaccaride from !or:L.eef lung"
o ow it wor:sC
increases affinity of antitrom.in to trom.in < .inds trom.in directlyN
inactivates !latelets&
Releases 5issue 6actor 'atway ini.itor
Releases endotelial 5'A
o Activity vs J and 22 H )C) ratio"
age %)
o alf life G0 min" some say %0 min
o cleared .y endotelium and macro!age .inding"
renal if ig dose of e!arin is given"
o more cance of !latelet ini.ition com!ared wit AM-?"
o reversal wit !rotamine"
o can .e given iv and sc"
o monitor anti Ja" '55" AC5"
o more .leeding and ?25 com!lications H ?25 seen in a.out *O ris:
Aow Molecular -eigt ?e!arin H F000,8000 #a"
en;ymatic de!olymeri;ation of U6?"
activity vs J and 22 in 2,FC) ratio"
li:e e!arin" releases 5issue 6actor 'atway 2ni.itor"
alf life G " renal clearance"
less !tt ini.ition" only sc administration"
no need to monitor"
less .leeding and ?25 com!lications, ?25 seen in a.out 0&*O
112.Prota!ine !ec"anis! of action:
o Cation tat .inds e!arin )C) ratio
o Restores A5222 to its9 inactive state
113.Direct &"ro!.in in"i.itors:
Ai!irudin " Argatro.an" irudin& 2ni.it 5rom.in directly& Can9t .e reversed&
Argatro.anC
As: for ematology consult
?alf life H F* min" onset in E0 min" ma/ effect in ),2 ours
Kive infusion of 2 mcgL:gLmin
Iee! a'55 at )&*&,2&*
Can9t reverse
DISORDERS OF COAGULATION
114. HI&:
o Q *0O !!t dro! OR !!t R)00"000 OR resistance to e!arin wit trom.otic
com!lications wile on e!arin
o Can .e seen as a la.oratory finding 04ust ?25 H e!arin induced trom.ocyto!enia1
or a clinical finding wit trom.osis 0?255 H e!arin induced trom.otic
trom.ocyto!enia1
o 'latelet dro! in * O of !ts on e!arin for Q * dyas
o Ma4ority wit ongoing e!arin use
age %2
o More cance wit U6? ten AM-?
o 5y!e ) H non immune related" inconse>uential
o 5y!e 2 H 2g K vs '6F
o #sC
!latelet aggregation"
serotonin release assay"
BA2SA 0for 2g K and '6F,e!arin com!le/1
o Alternative to e!arinC le!irudin" argotro.an" dana!aroid&
115. Hypercoagula.le state:
o ?ig ris: of trom.osisC
Antitrom.in deficiency
'n C< S def
?25
Anti!os!oli!id
o Aower ris: of trom.osisC
6actor V Aeiden
?y!eromocystenemia
'rotrom.in 202)0 !olymor!ysm
Ano(he" ,a$ (o %+assi'$ h$5e"%oagu+ab+e s(a(e-
A"(e"ia+-
'latelet a.normalities
y!erfi.rinogenemia
li!o!rotein 0a1
aterosclerosis
<)TH &enous and a"(e"ia+-
y!eromocysteinemia
?25
elevated 'A2,)
anti!os!oli!id A3C
o cardioli!inLlu!us anticoagulant
Genous-
6actor V leiden
!n 202)0 A !olymo!ysm
!n C < S
antitrom.in
dysfi.rinogenemia
age %E
116. Antip"osp"olipid anti.odies: )$AC/ AC$ and S$:
o 2K directed vs !os!oli!ids
o 6amily of !ns" one of tem is AB 0lu!us anticoagulant1
o 5ey ave .ot !ro coagulant and anticoagulant activity ,
2n vitro" tey !revent coagulation factors from interacting" slowing
coagulation 0'55 !rolongation1
2n vivo H tey do not ini.it any coagulation activity" .ut encourage it troug
!oorly understood mecanisms H
endotelial damage"
ini.ition of !rostocyclin secretion"
interference wit fi.rinolysis&
o SAB can .e associate wit
Systemic arterialLvenous trom.osis
Recurrent a.ortion
Neurologic disease
o Au!us anticoagulant < anticardioli!in anti.ody seen in association wit SABC
LAF 2 Q4K 6&s 3K in gene"a+ 5o5u+a(ion#
o A 'o+d "is= o' DGT
AFL 2 44K 6&s u5 (o LK in gene"a+ 5o5u+a(ion#
o 3 'o+d "is= o' DGT
o Ris: of arterial trom.osis is 2*O&&&
117. Resistance to acti*ated factor -:
o Most common a.normality associated wit V5B
o Resistance to inactivation of factor V .y activated !rotein C
o ?ence" activation of 22 is not ini.ited
o Clinical effects de!end on weter two 0omo1 or one 0etero;ygous1 co!ies of te
mutated gene are !resent
?eterogenous H + fold increase of trom.osis"
omo H 80 fold

118. Causes of !esenteric t"ro!.osis:
2dio!atic H most common
?y!ercoag state 0deydration aggravates tis1
Venous congenstion
o C?6
o !ortal y!ertension
in4uryC
age %F
o trauma
o !ost surgery
o inflammation 023#" !ancreatic1
o infection 0se!sis" a.scess" !eritonitis1
CD@ Co!!on ac2uired causes of .leeding and t"eir treat!ent:
o ?e!arin use H
anti 22 via A5 222" 56'2" t!a" !latelets
elevated '5L'55LAC5"
use !rotamine
o Argatro.anLirudin H
direct anti 22"
ig '5L'55"
use 66'
o warfarin" liver failure" malnutrition" .iliary o.structionC
lac: of J" 2J" V22" 22 0)%+21
elevated '5 only
use 66'Lvit I" octa!le/
o dilution
fewer molecules or cell mem.ranes around
re!lace missing su.stances
o .one marrow failure
trom.ocyto!enia
2# .y .one marrow ./
!latelet transfusion
o acidosisLy!otermia
diminised en;ymeL!latelet function
correct causeLwarm u!
age %*
o #2C
Klo.al activation of entire clotting
Consum!tive coagulo!aty
Correct cause" re!lace factors
#o NO5 give antifi.rionlytics
o 5rom.olytic tera!y
Reduced fi.rinogen" clot lysis
Blevated 6#'" BCA5
Kive cryo!reci!itate
o 'rimary fi.rinolysis
Reduced fi.rinogen" clost lysis
Blevated 6#'" BCA5
Kive antifi.rinolytics 0gamma amino ca!roic acid1
o Uremia
2m!aired !lateletLendotelium function
Aengtened .leeding time
d#AV'
o as!rinLK' 22.L222a use
!ermanent !latelet dysfunction
lengtened 3leeding time
!latelet transfusion
o s!ecific ini.itor
antifactor" usually V222
seen as resistance to factor re!lacement
give iger dose" immunosu!!ression
THROMBOLYSIS
119.&ypes of t"ro!.olytics:
Stre!to:inase H rarely used" does not directly activates !lasminogen" need to form activator
com!le/ first&
Uro:inaseC directly activates !lasminogen H .ot circulating AN# .ound to fi.rin
o C#5 wit infusion witin te trom.us
o #oseC
2*0"000 2U lacing .olus s!rayed into clot
ten infusion F000 2ULmin fo F " ten 2000 2ULmin for u! to EG
o Re,evaluated !ts at G,)2 ours
t'A H activates fi.rin .ound !lasminogen ONA= tus limiting systemic effects
age %G
o C#5
o loading dose is 2,* mg
May give u! to E times at *,)0 min interval"
ten infusion at 0&0* mgL:gL H i&e& E&* mgL for +0 :g !t&
o 6or all trom.olytics monitor fi.rinogen
o Com!lication of trom.olysisC
!uncture site emorrage
distal em.oli;ation
!ericateter trom.osis
intracranial emorrage 0R) O1
alte!lase H li:e t'A" .ut iger affinity for fi.rin and longer alf,life
120. Contraindications to t"ro!.olysis:
o A.solute
CV event 0including 52A1 in !ast 2 monts
2ntracranial trauma 0e&g& neurosurgery1 in !ast E monts
active .leeding
K2 .leed in !ast )0 days
o Relative ma4or
5rauma < surgeryC
o ma4or non,vascular trauma or surgery in !ast )0 days
o C'R in !ast )0 days
o recent eye surgery
o !uncture of uncom!ressi.le vessel
uncontrolled ?5N 0Q)80L))01
2C tumor
o Relative minor
e!atic failure wit coagulo!aty
.acterial endocarditis
!regnancy
dia.etic emorragic retino!aty
121.&"ro!.olysis studies su!!ary:
Rocester trialC surgery vs trom.olysis
))F !t randomi;ed
Same lim. salvage at ) mont
Same survival at E0 days
.ut worse survival for surgery at ) year
age %+
S52AB trialC
surgery vs trom.olysis for iscemic AB&
2nitially !ts were not randomi;ed according to duration of iscemia
all analysis was done after te trial was com!leted on su.sets of !t !o!ulation
o ence" source of .iasM
o Acute 0R)F days since onset1 at E0 days
Overall" no difference"
e7%e5( need 'o" am5u(a(ion a'(e" 'ai+u"e o' su"ge"$
Surgery ad more am!utation .ut it is non,significantM
Aysis Surgery
Am!utation GO )+O 'U0&0G" NS
Am5 a'(e" 'ai+u"e Q0K A8K 'U0&0)
3leeding GO 0O
Mortality *O *O
o Cronic 0Q)F days since onset1 at E0 days
Same mortality 0FO1 and am!tation 0FO1
Do" &e"$ high "is= 5(s, su"&i&a+ a( 1 $ea" ,as be((e" in +$sis %om5a"ed
(o su"ge"$ 6LK &s Q3K#
o Native vesselsC 2E+ !ts
Aess am!utation and iscemia at ) year wit surgery
Aysis Surgery
2scemia @ ) year GFO E*O
Am!utation @ ) year )0O 0O
o 'rosteticC
AcuteC lysis .etter tan surgery
Aysis Surgery
Am!utation )year 20O F8O
CronicC
o Same rates of am!utation for surgery and lysis
o 5o!a;C
#o;e !ase H F000 uLmin followed .y M
RC5C same lim. salvage" same survival" less surgery in trom.olytic
grou!
Th"ombo+$sis ("ia+s %on%+usion-
o ) year mortality is )0,20O
age %8
o Aysis as intracranial .leeding rate of u! to 2O"
All .leeding com!lications , *O
-it t'A lessM
o 9n a%u(e se((ing &s %h"oni% se((ing, +$sis is eBui&a+en( (o su"ge"$ ,"(
mo"(a+i($ and +imb sa+&age ,i(h se&e"a+ %a&ea(s-
o L$sis has ad&an(age-
2n acute setting"
less am!utations if !rocedure fails
.etter for !rostetic occlusion
2n cronic settingC
May ave long term advantage for very ig ris: !ts
o Ja(i&e a"(e"$ (h"ombosis is be((e" add"essed (h"ough su"ge"$

6or vein grarts" .est results wit trom.olytics are acieved for !ts witout #M and in late
failures as o!!osed to early&
3ecause trom.olysis trials did not demonstrate SU'BR2OR25= of trom.olysis" it is not clear
wic metods sould !referentially .e used in AA2& Overall" in !ractice surgery is !referred&
122.Intraoperati*e t"ro!.olysis: "ow to?
o 2m!ortant !art of trom.ectomy
o Camerota RC5 of uro:inase sowed tat intrao! route is safe" no !lasminogen de!letion"
and lower mortality com!ared to !lace.o
o After trom.ectomy is done H do angio&
o 2f clot is gone H occlude artery and .olus 2A lytic in distal .ed
2,8 mg t'A or )00"000,2*0"000 uro:inase
o 2ncom!lete trom.us H eiter re!eat .olus or restore !erfusion and start 2A dri!
wit cateter
o B/tensive residual trom.us H
2solated lim! !erfusion
B/sanguinate lim.
2*0 mm .lood !ressure cuff to tig
Canulate !o! vein wit red ru..er cat
Canulate A5 and 5'5
2nfuse *00"000 uro or *0 mg t!a into eac artery in *00 cc of NS
over 20 min
#rain vein" flus out wit anoter ) A NSLe!arin
Restore circulation
age %%
Can :ee! cuff for u! to )
Most of !lasminogen activator esca!es via vein& Some will go into
.one marrow ,Qsystemic
Angio4et C
o Reduced incidence of distal em.olisation
o No !ros!ective study surgery vs mecanical device is availa.le
o Retros!ective studyC
o .etter survival" .etter !atency" same am! free survival
angio4et Surgery
FL)2 !atency +8O G+O !U0&0)+
GL)2 survival 88O +*O !U0&02
Am! free survival )2L)2 ++O G)O !U0&0+
DVT
123.Diagnostic criteria for D-&: CD1?
Acute H less tan 2 wee:s
Su.acute H .etween 2 wee:s and G monts
Cronic H more tan G monts
C UVenous incom!ressi.ility
o Most im!ortant criterion" te rest are su!!ortive
#U distended large vein in ACU5B setting
o 5rom.us visuali;ation H ecolucent
o Vein is contracted and clot is eterogenious in C?RON2C #Vt
6UA.sent or diminised s!ontaneous flow
o A.sence of res!iratory !asicity
ins!iration augments UB flow" decreases AB
o A.sent or incom!lete color filling of lumen
AdditionalC
Com!are wit contralateral side
R*0O diameter increase wit Valsalva 0i&e& no res!onse to !ro/imal
o.struction1
immo.ile venous valves
124. R1 and outco!es for D-&:
80O of 'B are clinically silent
age )00
VS as ig false !ositive rate
RuterfordC
#V5 H seen in 20O of !ts undergoing Ken surgical !rocedure
6atal 'BC
Ken surgery H 0&+O witout !ro!yla/is
o #own to 0&)O wit e!arin
Blective i! H 2,EO
?i! fracture H F,+O
Ruterford !& 2)EG
After #V5" veins -2AA recanali;e
Rate and recurrence of #V5 will determine via.ility of valves
o And incidence of CV2 and '5S
2n 2LE" valves will .e damaged and will lead to !ost,trom.otic se>uellae
?istological evidenceC
o 5rom.us organi;ation rarely involves valve cus!
o Clear ;one around valve due to endotelial fi.rinolytic activity
2* year study of MorC )*00 !ts
5ime CV2 incidence
) +O
* )FO
)0 20O
20 2*O
Venous Ulcers at 20 years Sur!ising EO
?owever" !ro/imal o.struction will increase ris: of CV2
%*O of !ts wit iliofemoral trom.osis treated .y AC alone ave am.ulatory venous
y!ertension at * years
o %0O ave sym!toms of CV2
o )*O ave ulcers
o )*O de.ilitating venous claudication
Argument to clear iliofemoral clot .urden
o Biter wit C#5 or o!en trom.ectomy
o See iliofemoral trom.osis notes
RD 'o" DGT-
o Age C F0 yoa
o 2mmo.ility
os!itali;ation
age )0)
neurologicL!aralysis
travel
o 5rauma
surgery H de!ending on ty!e
o neuroLortoQ generalQBN5
trauma
o Venous tn
C?6
venous insufficiency
o ?y!ercoagula.le state
OC'
fam /
see ?CS
malignancy
!regnancy
o Systemic inflammatory state
SAB
23#
Lo, "is=
)1 R 40 yrs age
3# Jone o' (he "is= 'a%(o"s +is(ed
E1 Keneral anestesia for R Q0 minu(es
F1 Minor elective" a.dominal" or toracic surgery&
-itout !ro!yla/is !ro/imal DGT "is= R 180 K
6atal 'B R 0&0) O
'ro!yla/is , ea"+$ ambu+a(ion
Mode"a(e "is=
)1 > 40 yrs
21 Keneral anestesia > Q0 minu(es
E1 ) or more ris: factors
DGT 3 / 10 K
6atal 'B 0&) , 0&+ O
'ro!yla/is H A#U? *000u 3id or 5id" )R intermittent com!ression until am.ulation
High "is=
age )02
)1 > 40 years
21 Surgery for ma+ignan%$ or an o"(ho5edi% 5"o%edu"e
E1 Keneral anestesia Q E0 minutes
F1 ?ave an inhibi(o" de'i%ien%$ s(a(e or o(he" "is= 'a%(o"s
'ro/imal #V5 10 / 30 K
6atal 'B )&0 , *&0 O
'ro!yla/is H LMWH od AJD 2C until am.ulation
#r& -ells 0University of Ottawa1" et alC Aancet )%%+N E*0C )+%*,)+%8
active cancer 0ongoing treatmentLdiagnosed witin G monts or !alliative care1, score )
!aresis" !aralysis or recent !laster cast immo.ilisation of lower e/tremity, score )
recently .edridden for more tan E days andLor ma4or surgery witin F wee:s, score )
localised tenderness over distri.ution of dee! veins, score)
entire leg swollen, score)
calf swelling more tan E cm com!ared wit asym!tomatic side" measured at )0 cm
.elow ti.ial tu.ercle, score )
!itting oedema 0greater in sym!tomatic leg1, score )
collateral su!erficial veins 0non,varicose1, score )
alternative diagnosis as li:ely or greater tan tat of #V5, score SU35RAC5 2
2n !atients wit sym!toms in .ot legs" te most sym!tomatic leg is used
score 0 or less, low ris: 0EO !ro.a.ility #V51
score ) or 2, moderate ris: 0)+O !ro.a.ility #V51
score E or more, ig ris: 0+*O !ro.a.ility #V51
age )0E
125.D)di!er in diagosis of D-&:
o Measure #,dimer in out!atients wit low !retest clinical !ro.a.ility
o 'roduct of fi.rin degradation
Aow !retest !ro.a.ility ris: !ts H N'V %%O"
ig !retest !ro.a.ility ris: !atients H N'V E*O
o 2f !retest !ro.a.ility is low" order #,dimer&
2f it9s low" you9ve ruled out #V5
o 2f 'retest 'ro. or #,#imer is ig H need to order du!le/
One negative du!le/ rules out #V5
Cost of first follow u! du!le/ is E%0"000a !er life saved
Cost of second follow u! du!le/ is E&* mln a !er life saved
126.%ays to treat D-&:
o BlevationL.ed rest PL, AC
o AC alone
age )0F
o AC P 2VC interru!tion 0filter1
o C#5
-ill decrease !ost trom.otic se>uellae of iliofemoral dvt" NO5 fem,!o!
0large venous registry1
2 small RC5 did not sow difference wit AC for fem,!o!
Kreat for acute #V5 0R)0 days1
Aarge R5C is needed H !ending 5OAB#O
2f fails H 'C mecanical trom.ectomy
o Surgical trom.ectomy , for 2A2O6BMORAA #V5
6or active am.ulatory !ts OR (o 5"e&en( venous gangrene in !alliative !t
Swedis RC5 H )0 year !atency 80O vs E0 O 0AC alone1
Muc .etter !atency and valve function com!ared to AC alone
o Surgical .y!ass if 2VCL2liac occlusion AN# s/s
5reatmentC
?e!arin,Qwarfarin
Bno/o!arin 0)mgL:g .id or )&*mgL:g od1,Qwarfarin
?ow longC
A.ove :nee #V5" no 'B H
o E monts treatment
o Blevate leg" com!ression ose" may return to wor: in 2 wee:s
o #u!le/ at +2" ) mont" G monts
o Multi!le follow u! du!le/ is NO5 cost effectiveM
A.ove :nee #V5 wit 'B or recurrentC
o G mont treatment
o E
rd
e!isode H life time AC
3elow :nee #V5 H some say follow wit #u!le/" some say treatM 29d treat for fear of
20O !rogression& Alternatively" may follow wit serial #o!!ler US in ) wee:& 5e only
#V5 tat is safe not to treat is tat of soleal sinuses and o.serve
Most common vein to trom.ose H !eroneal" least common H anterior ti.ial&
age )0*
127.Indications for I-C filter:
o A.soluteC
Need to anticoagulate .ut !t as contraindications
Need to anticoagulate .ut develo!ed com!lications wit AC
'ost !ulmonary em.olectomy
!rev caval interru!tion 0ligation or filter1 failed
o RelativeC
6loating 2liofem trom.us
'ro!agating iliofemoral trom.us wile on AC
Se!tic 'B
Cronic 'B in !t wit 'ulmonary y!ertension and core !ulmonale
't wit Q *0O !ulm vessel occlusion wo can9t afford to lose
more !ulm function wit recurrent !ulmonary em.
ig ris: of falls H as in severe ata/ia 0can9t anticoagulate1
asideC
'RB'2C
F00 !t wit !ro/imal #V5
All are AC9d" alf ave 2VC filter !ut in
At )2 days more 'B in non 2VC grou! FO vs )O
?owever" tere was NO difference in Mor.idity or mortality related to 'B at 2 years
5ere is increased ris: of su.se>uent #V5 if ave 2VC filter in !lace
o )0O vs 20O
o Still" no role for !ro!ylactic anticoagulation if ave filter in !lace
Are 2VC filters all5?A5 necessaryD
?ence argument for retrieva.le filterM
5em!orary filter H ave wireLseat attacment
Retrieva.le filter H li:e regular filter .ut can .e removed at a later date
Cancer !ts ave very ig rate of #V5 and 'B
128.Co!plications of I-C filter:
o @ !lacementC
Access .leedingLarterial in4uryL!seudoaneurysm
2VCLSVC in4ury
2ncom!lete de!loyment
Mis!lacement
Renal contrast load
o -ile in !laceC
Migration
O.struction wit clot
2nfection
Recurrent 'B
age )0G
o @ removalC
Access .leedingLarterial in4uryL!seudoaneurysm
6ailure to retrieve
Renal contrast load
in4ury to SVCL2VC
129.#igratory p"le.itis:
Seen in !ancreatic ca" .uerger disease" .ecet9s disease" 'AN&
Su!erficial !le.itis as 20O ris: of 'B H NO5 a .enign entity
130.ffort t"ro!.osis: classify
6re>uencyC
o 'rimary H effort H 2*O
o Secondary H
Central lines F0O"
infection" !rev #V5" UB AV6" y!ercoag state" trauma H E*O
!atC
venous ?5N" related to o.struction" rater tan reflu/
AC ma:es no difference on degree of disa.ility
'B incidence H +O
o 'rimary H
Sometimes see anatomic defect in 5O
young males
dominant e/tremity in +*O
+*O re!ort strenuous re!eated activity !rior to onset
o Secondary H
CV cateter MC" malignancy" infection" trauma" trom.ocytosis
to treat" 4ust remove cateter" consider AC onlyM
131.&reat!ent options for pri!ary axillary *ein t"ro!.osis:
)bse"&ee+e&a(eAF vs in(e"&ene
T"ea(men( o5(ions 'o" 5"ima"$ a7i++a"$ &ein (h"ombosis-
)& AC" and wait for te clot to go away" vein to recanali;e
2& Cateter #irected 5rom.olysis" to actively o!en u! vein
E& 5oracic outlet decom!ression if e/ternal com!ression demonstrated"
F& O!en Angio!lasty vs stent for intrinsic residual stenosis in te vein"
*& surgical .y!ass for failed trom.olysis AN# disa.ling sym!toms&
age )0+
Confusion and variation .egin wen you factor in timing and order of tese interventionsM
?ere is te a.ove list wit timing considerationsC
A8 F)J;ERGAT9GE a55"oa%h-
Arm BlevationLRest alone
not !ractical for most active !atients
for ig ris: only wit minimal function and AC Contraindications
An(i%oagu+a(iona"m e+e&a(ion"es( a+one
."e'e""ed a55"oa%h o' mos( o' %onse"&a(i&e hema(o+ogis(s
.oo" 'un%(iona+ "esu+(s a%%o"ding (o Ru(he"'o"d:
'lease note" tat AC alone ma:es no difference on degree of future disa.ility H i&e& it does
not im!rove function muc&
'B incidence H +O
<8 9JTERGEJT9)JAL a55"oa%h-
o!en u! vein wit C#5 0most commonly1 vs o!en surgical 0not common as a
stand alone H unless com.ine wit immediate 5O# and o!en veno!lasty1
0ues(ions a"ise as (o WHEJ (o do T)D i' su%h is diagnosed-
o!en u! vein wit C#5 andLOR anticoagulate for E monts" ten venogram
i' e7(e"na+ %om5"ession a+one, (hen T)D8 Mos( %ommon s%ena"io8
2f internal defect alone" o!en veno!lasty vs .alloonLstent
if normal venogram H E monts of ACLABLR&
o Aeast common scenario&
o 5en decide on sto!!ing AC vs continuingM
AdPun%(s 'o" &ein de'e%(s-
for sort stenotic segment
a& o!en veno!lasty
.& endovascular !lasty PL, stenting
for long stenotic segment
a& trial of ACLABLR& 2f fail" ten consider venous .y!ass or 2$
turndown
5O#C
On e/am" (he %+assi% ans,e" ,ou+d be (o +$se 6i' no %on("aindi%a(ions#, =ee5 AF 'o" Q
mon(hs, (hen b"ing 'o" de+a$ed T)D i' indi%a(ed b$ &enog"am8
MAIB sure you let te !t coose and review com!lications of trom.olysis 02C
emorrage1 as well as contraindications to trom.olysis&
age )08
132.Iliofe!oral -enous t"ro!.osis:
o Aggressive a!!roac H
ig rate of sig !ost trom.otic se>uellae tat are difficult to
manage conservatively
early relief of o.struction may !revent suc se>uellae&
'legmasia cerulean dollens H o.struction of AAA venous outflow&
'legmasia al.a dollens H o.struction of only MA$OR venous
outflow" wit !atent su!erficial outflow&
o Al.a H .ecause of concomitant arterial vasos!asm&
o 2liofemoral trom.ectomyC
anticoagulate
C5 first to assess caval involvement
PL, 2VC filter
KA" )0 mm 'BB' to decrease 'B cance
6ascitomy first if !legmasia cerulean dollens
KSV 4unction dissection" C6V to inguinal lig
Aongitudinal venotomy of C6V
6ogarty !ro/imal" esmar: distal e/tremity
KSV to S6A anastomosis" close in G wee:s
o #iameter fistulaLartery ratio )LE
o No more ten E00 mlLmin flow
Com!letion venogram H A MUS5
o 2f iliac v& stenosis H !lastyLstent
Iee! anticoagulated
CHRONIC VENOUS INSUFFICIENCY
133.-enous flow c"aracteristics:
!asic
o if continuous
sus!ect !ro/imal o.struction
o if !ulsatile
sus!ect AV6 or 6luid overload 0R C?6" venous ?5N1
unidirectional
s!ontaneous
res!onds to ins!iration and e/!irationLValsalva
age )0%
o U!!er e/tremityC U' wit ins!iration and #O-N wit e/!iration
i&e& augmented .y negative !ressure of te cest
o Aower e/tremityC #O-N wit ins!iration and U' wit e/!iration
i&e& augmented .y negative !ressure in te a.domen
134.Deter!inants of *enous flow:
6rom distal to !ro/imalM
o Arterial inflow
o 3ody !osition
o Calf muscle activity
o valves
o 'eri!eral resistance
o A.undance of collaterals
o 2ntraa.odminal and intratoracic !ressure
'ase of res!iratory cycle
o R eart !ressure
135.Cause of C"ronic *enous insufficiency:
o Venous stasis
#ue to valveLendotelial damage" stasis leads to nutritional
de!rivation of s:inLtissue&
?owever" no canges in O2 sat sownM
o AV fistula teory
?y!otesi;ed arteriovenous connections
2ncreased sunted flow
Not confirmed o.4ectively
age ))0
o 6i.rin cuffC diffusion .loc:
Cuff on !reca!illary vessels" acting as diffusion .arrier&
Not true
o Aeu:ocyte tra!!ingC
Acce!ted teory&
Activation of neutro!ils in venous microcirculation&
o leads to degranulation" endotelial damage&
affects diffusion of nutrient and o/ygen"
results in ulcers and s:in damage&
136.%a*e for!s of *enous plet"ys!ograp"y in se*ere S18 reflux:
Am.ulatory venous !ressureC
o AV' H !ressure in te dorsal !edal vein after )0 calf contractions
RF0 H low ris: of ulcer
Q80 H 80O cance of ulceration
Return to .aseline in Normal sould .e Q E0 sec
i&e& #BAA=B# refilling is NORMAA
o ''K and A'K are non,invasive su.stitutes of AV'
'oto!letysmogra!yC
3 H a.normal" VR5 0venous refilling time1 is sort
C H normal
3aseline H
!t standing"
followed .y )0 ti!,toe calf contractions H
o em!ties te leg vein
return of venous .lood is documented
o eiter .y strain,gauge
o !oto!letysmogra!yM
age )))
'oto 'letysmogra!y H
''K uses a transducer tat emits infrared ligt from a ligt,emitting diode into te
dermis&
5e .ac:scattered ligt is measured .y an ad4acent !otodetector
o dis!layed as a line tracing&
As .lood fills in" it a.sor.s te ligt
o 5is returns curve to .aselineM
o 5e faster te !ooling" te faster te return to .aseline
Ra!id return to .aseline is caracteristic of venous insufficiency&
Air !letysmogra!yC
Unli:e ''K" it sam!les large calf volume&
Air !letysmogra! data o.tained from tracings& VV" venous volumeN V62" venous filling inde/N
B6" e4ection fractionN RV6" residual volume fractionN BV" e4ected volumeN RV" residual volumeN
V65" venous filling time&
Aie down" ten stand u!" ten em!ty veins wit single contraction 0B61" ten em!ty veins wit
multi!le contractions&
Normal VV is 80,)*0 ml
Residual volume is RE*O
age ))2
GD9 / R 3 m+se%,
o i' "e'+u7 i( is > Q0 m+se%
Siebe+ sa$s L m+se%
o i&e& curve is stee!er wit CV2
B6 H e4ection fraction H after single ti!,toe H no"ma+ > A0K
Some use 52MB to refill alone H shou+d be +ess (han 3M se% (o diagnose insu''i%ien%$
Note " do not confuse V62 0normal R E0 mlLsec" some say 20M1 and time to return to .aseline
0normal Q E0 sec1
Can9t do 'K on !ts wo can9t stand unassisted or can9t do ti!toe&
#u!le/ of S6$ reflu/C
#o su!ine e/am for #V5
May do Valsalva H
less tan 2 sec reversal of flow at S6$ sould .e seen wen !t su!ine
Stand u!" cuff to lower tig" #o!!ler at S6$
2nflate cuff" noting disa!!earance of !rograde flow
Ra!idly deflate cuff H noting reversal of flow at S6$&
N R0&* sec of reflu/" if more H reflu/&
137.-enous disease assess!ent: CAP classification
Venous y!ertension causes e/travastion of al.umin and R3C&
o R3C can9t re,enter circulation H .rea: down and !roducts of teir decom!osion
stimulate vicious inflammatory reaction&
o -3C migrate in
o troug 5K6,b,)" fi.ro.last creat intense fi.rotic reaction H UN2SUB to CV2& 2n
te end" fi.rosed inverted .ottle nec: legs are formed&
Varicous veins H wit venous ?5N" SMC transform form contractile to secrotory
su.ty!e&
5raditional tin:ing H
o !rimary CV2 H tic:ened vein" normal valve
o Secondary CV2 H tic:ened valve" normal vein
o 2n reality" see elements of .ot , i&e& .ot vein and valve may .e a.normalM
o C H clinical signs" add A 0asym!tomatic1 or S 0sym!tomatic1
)& 5elagectasia" reticular veins" malelar flair& #iameter R E mm
5ese do not need du!le/ study
2& Varicose veins H i&e& diameter Q E mm
5ese need du!le/ study
E& Bdema" no oter canges
F& ;=in %hanges 2 5igmen(a(ion, +i5ode"ma(os%+e"osis
age ))E
*& S:in canges P ealed ulcers
G& S:in canges P active ulcers
o B H etiology
C H congenital" since .irt
' H !rimary" idio!atic
S H secondary
o A H anatomy
S H su!erficial
# H dee!
' H !erforators
o ' H !ato!ysiology
R H reflu/
O, o.struction
R"O H .ot
Venous clinical severity scoreC validated E0 !oint tool to assess disease&
138.Approac" to *enous ulcers:
o Confirm venous etiology
?istoryLe/amLdu!le/ H KSVLdee!L!erf incom!etence
On /C
Varicosity 0since .irt vs BVBN51
#V5L!regnancyLvein t/Larvest
Occu!ation
OC'Lfam /
Race
o African American H !erimalelar ulcer H tin: sic:le cell
o RLo arterialLneuro!aticLinfection contri.ution
o ?eal ulcer conservatively
Blevation" Com!ression" infection treatment
o 2f does not eal after E monts" rLo malignancy and consider an intervention
2ndication
.leeding
'ain
o Acing !ain
o Aeg eaviness
o Basy leg fatigue
Su!erficial trom.o!le.itis
cosmesis
CBA' F , G
o Ulcer
o B/ternal .leeding
o An:le y!er!igmentation
age ))F
o Ai!odermatosclerosis
o S:in atro!y
Expanded Aside:
Classify varicosities H
congenital"
!rimary 0underlying structural !ro.lem1"
secondary

#istinguis !rimary from secondary varicositiesC
'rimaryC
early onset" fam / of varicosities&
'reci!itatitng factorsC after !regnancy" e/ternal com!ression 0may turner" !elvic mass1&
SecondaryC
will ave / of normal lim." ten #2S52NC5 event 0#V5LtraumaLiatrogenic surgery1"
y!ercoagula.le stateLfam / of suc"
contrace!tive use"
AV fistula&
?istory sould always includeC
!rofessionLlong u!rigt standing&
Review !revious ulcerLvein surgeryLtreatment
o com!liance and wor: u!&
istory of vein arvest"
#V5
!regnancy"
y!ercoagula.ility"
trauma
avf
/ of 2CLrest !ain
R6 for Ateroscelrosis as te ulcers will turn out to .e mi/ed in origin
o smo:ing" tn" l" omo" dm" cvaLmi
os!ital admission
AsideC
Classify varicosities H
congenital"
!rimary 0underlying structural !ro.lem1"
secondary
age ))*

#istinguis !rimary from secondary varicositiesC
'rimaryC
early onset" fam / of varicosities&
'reci!itatitng factorsC after !regnancy" e/ternal com!ression 0may turner" !elvic mass1&
SecondaryC
will ave / of normal lim." ten #2S52NC5 event 0#V5LtraumaLiatrogenic
!rocedureLsurgery1"
y!ercoagula.le stateLfam / of suc"
contrace!tive use"
AV fistula&

On e/amC
-it !rimary" li:ely see S6$ involvement only" i&e& !redominantly su!erficial reflu/
o i&e& no !erfLdee! vein !ro.lems
o less remar:a.le CV2 stigmata&
Secondary will ave more advanced disease
o #ee! refulu/" !erforators" significant CV2 stigmata
ins!ect H
o swelling" vari/" ulcer , veinC !in:" clean .ottom" flus wit s:in level" moderately
tender to !ainless" .etter wit elevation" .leeds on !ro.ing" gaitor area"
o normal !ulses"
o signs of CV2
telangecatsiaLreticular 0)1"
varicose 021"
swelling 0E1"
s:in canges , atro!y .lance" li!odermatoscleoris 0F1"
ealed ulcer 0*1"
active ulcer 0G1&
AsideC
o Arterial ulcer , !ale fi.rinous necrotic .ottom" distal foot" !ainful" !unced out"
!oor !ulses" .etter wit de!endency" signs of 'A# and R6 on istory !lus 2CLrest
!ain&
B/am cont9d
auscultateC .ruit for 'A#
!al!ateC 5rendelen.erg" !ulses
Asses reflu/ in su!erficial and dee! system and !erforators&
age ))G
5rendelen.erg test H
su!ine" elevate leg" com!ress KSV 4unction or ASV 4unction&
Stand u!" maintain com!ressionC
o watc fast refilling of vein from .elow H cec: !erforators
Release com!ression H
o see fast refilling from a.ove H cec: in line valve insufficiency
6inally" investigationsC
#u!le/
6irst cec: for #V5 wen su!ine" and Q 2 sec reflu/ at S6$ wit valsalva
U!rigt H cec: for Q0&* sec reflu/ wit cuff deflation distal to S6$
Venogra!y H rarely )st
Ascending for o.struction
#escending for reflu/
'ressure gradient studies if sus!ect o.struction
A32 PL, angio if necessary
C5LMR2 if sus!ect central o.struction
Ambu+a(o"$ &enous 5"essu"e-
o 'ressure in te dorsal !edal vein after )0 conse>uitive calf contractions&
o Sould di! from 80 mm ?g standing to 20,E0 mm&
2f going u! H sus!ect !ro/imal o.struction
o Sould ta:e E0 sec or more to return to 80 mm wit standing >uietlyC
2f faster H sus!ect valve incom!etence
''K and A'K are non,invasive su.stitute for invasive AV' measurement&
Fonse"&a(i&e ("ea(men(-
Com!ression
#ressing cange H #R= gause
Blevation
ASALiodosor.L!ento/ifyllineL'rostoglandin
o !& 22F*,F+
o NO occlusive ydrocolloid dressings 0duoderm1
same ealing rates as dry" may .e more infection
Com!ressionC RuterfordC E0,F0 mm ?g .elow :nee
Sigvaries recommends te following C2C
age ))+
Abso+u(e %on("aindi%a(ions-
Advanced !eri!eral o.structive arterial disease
Severe neuro!aty 0dia.etic1
Congestive eart failure 0active1
Se!tic !le.itis
'legmasia coerulea dolens
Una.oot H glycerin" ;n o/ide" camomile" sor.itol" mg" al silicilate
2f mi/ed ulcer in old gentleman and A32 0&G , may try ligt !rofore dressing for E,F wee:s
9' no( im5"o&ing / "e&ie, diagnosis-
rLo non,com!liance
mimic:ersC
o C5#
o ?5N
o Malignancy
o 'yoderma gangrenosum
o Calcifila/is in dialysis !atients
local and general factors !reventing ealingC
o infection
rLo osteomyeltis and w<w infections
o ongoing trauma
o stalled wound
need for de.ridement"
needs growt factors
o malnutrition
o immunocom!romised state
malnourised
cancer
cemo
Fonside" adPun%(s ,

intermittent com!ression
!romogranLregrene/L!latelet s!in,off to :ic: start stalled wound
a./ ivL!o if cellulitis
antimicro.ial in te wound
consider y!er.aric o/ygen
consider a!ligrafL!ento/yfilin" ilo!rost

age ))8
2f surgery necessary H
consider location and see if stri!!ing KSVLligation would el!&
9ndi%a(ion 'o" su"gi%a+ in(e"&en(ion- after E monts of intensive com!liant conservative
managementM
)& ulcer
2& !ain
E& .leeding
F& su!erficial trom.o!le.itis and trom.osis of KSV
*& cosmetic
?ealed ulcer is not li:ely to o!en u! again& ?owever" wit maintenance !rogram" E0O
recurrence is e/!ected& 2f no maintenance is adered to" )00O recurrence is guaranteed&
Overall" GO of !ts wit CV2 will !rogress to ulcer over * years 0Minessota study1&
139.(a!e *eins ligated during sap"enous *ein stripping:
su!erficial e!igastric
su!erficial circumfle/ iliac
su!erficial e/ternal !udental
o tese may .e left intact if you .elieve in neovasculari;ation
o Ruterford doesM
greater sa!enous
anterior accessory
!osterior accessory
140.%"y does *ein stripping surgery fail:
Surgical errorC failure to remove te KSV from te circulation
o Aigated S6$ only" not stri!!ed
o Missed du!licated sa!enous vein
o mistoo: accessory sa!enous vein for te KSV
Non,sa!enouse source of venous ?5NC
o !erforating veins wit incom!etent valves
genetic tendency to form varicosities
neovasculari;ation
asideC contrary to !revious dogma" Ruterford !oints out tat leaving some .rances intact
actually !rotects from neovasculari;ationM So it !ays to .e 7slo!!y8
141.-enous claudication: cause
o 3ursting dee! leg !ain wit e/ercise
o 'ro/imal venous o.struction" distal veins are usually normal
age ))%
o #ue to e/ercise induced y!eremia AN# increased venous outflow resistance&
142.C"ronic I-C=iliac=deep *ein o.struction:
o 2ntrinsic venous defectC
Acute #V5
Bndotelial scarringC
'ost cronic #V5
Radiation
A.normal venous we.s" y!o!lasia" a!lasia
o B/ternal com!ression
Retro!eritoneal fi.rosis
3enignLmalignant tumor
Cyst
Aneurysm 0arterial1
3andsLsli!s
May 5urner syndrome 0A common iliac vein com!ressed .y R C2A1
5estingC
#u!le/
'letysmogra!y
C5LMR2 a.domen
Resting armLfoot venous !ressure difference Q F mm ?g
Resting su!ine centralLfemoral !ressure difference Q * mm ?g
2 fold increase in femoral !ressure after e/ercise
o )0 dorsifle/ions at an:les
o 20 isometric calf contractions
Venogra!y H ascending X
o for OR !lanning
o 3Ll femoral vein !uncture
Venous stentC Kianturco Y stentC self,e/!anding" 8,F0 mm" good loo! strengt" no
forsortening" can use across tri.utaries 0renal vein1 H i&e& large cells
143.S-C o.struction:
3lindness and cere.ral emorrage is an uncommon com!lication&
CauseC
Cancer 0lung" mediastinal AN" tumors1 H 8*O
3enign H
o MOS5 Common H mediastinal fi.rosis"
o =atrogenic H due to cateters
5reatmentC
o 2f Cancer H radiation tera!y of !rimary
age )20
o 2mage from .asilic vein .ilaterally" ten attem!t to stent wit Kianturco Y stent
o 2f fails" consider central .y!ass vs 2$,femoral e/tra,anatomic wit KSV
144.%"y .ypasses for *enous repair are prone to failure?
o Aow flow due to
collateral circulation
distal venous o.struction
incom!etent valves
"emed$-
?/b$5ass, AGD, 5e"ioo5e"a(i&e in(e"mi((en( %om5"ession
o easily com!ressi.le grafts
due to low !ressure in te circulatin
de!endence on intraa.odminalLtoracic !ressure
location .eind inguinal ligLliver
"emed$-
e7(e"na+ su55o"(, +a"ge diame(e" g"a'(
o increased trom.ogenicity
most !t ave lac: of !n C" S" A5 222
syntetic grafts more trom.ogenic
"emed$-
use au(o+ogous g"a'(
use an(i%oagu+a(ion
su"&ei++an%e
145.$ist $ perforators:
o Connect KSV and dee! system
o Normally" direct flow form su!erficial to dee!
B/ce!t in foot H no valves tere
Allows for measurement of AV' in su!erficial dorsal vein
o Coc:ett 2" 22" 222
go from !osterior arc vein 0NO5 KSV1 to !ost ti.ial vein
o a:a vein of Aeonardo
F cm !osterior to medial edge of ti.ia
along Ainton9s lineC
o G" )2" )8 cm from floor"
coc:ett ) at med malleolus
o can9t get tis on wit SB'S
o 'arati.ial !erforators
'ro/imal location
2 cm medial to te medial edge of ti.ia" go from KSV to !osterior
ti. and !o! vein
o 5igC
age )2)
?unterian 0? for ig1 H in te mid ig tig
#odd9s 0# for distal tig1
3oyd9s 03 for .elow1 H .elow :nee
o Vein of Kiacommi H connects KSV and ASV
o )0O of veins are com!letely du!licated
o 2*O , !artially du!licated
o No valves in C6V or iliac veins
o 5o study !erforators" use descending !le.ogra!y
Aow false !ositive
?ig false negative
#u!le/ is .etter
146.Indications for perforator ligation:
ave to ave CBA' class F and a.oveM&
6ailure of conservative t/ of severe stasis sym!toms
Recurrent cellulitisLrecurrent #V5 during conservative treatment
Relative H non,com!liance
Contraindications to !erforator ligationC
Cronic 'A#
2nfected ulcer
Mor.id o.esity
Non,am.ulatory and ig ris: !t
RelativeC CR6" #M" Reumatoid artritis
ResultsC
)& #ifficult to distinguis .etween contri.ution of KSV ALS and !erforator surgery
2& ulcer ealing at )0 y H G0O
E& recurrence 20O 0F0O in !ost trom.otic lim.s1
F& im!roved emodynamics 0Am.ulatory Venous 'ressure1 in some .ut not all studies
*& !ossi.le tat sclerotera!y may .e .etter tan SB'S or surgeryM
SurgeryC
)& Su.facial Bndosco!ic 'erforator Aigation 0SB'1
2& O!en H modified 0for coc:et 21
E& O!en for te rest of tem H modified Ainton 0not done muc1
ResultsC SB'S O!en
Ulcer ?ealing %FO 88O
Ulcer recurrence ))O 22O
-ournd com!lications *O 2FO
age )22
DIALYSIS ACCESS
147.Principles of A-1 creation:
#OS2 wants at least *0O AV6 as autologous access&
o 2f sort term dialysis needed R E wee:s H tem! line 0>uinton1
o Cec: K6R if RE0 mlLmin
o Create access if antici!ate dialysis witin a year
o Autologous if !ossi.le
o Non,dominant lim.
o #istal !ortion of u!!er lim. first
o Venous imaging ifC
Bdema in arm
Collateral veins on cest on e/am
'revious linesL!acema:ers 0several1
'revious armLnec: surgery
o Su.cutaneous !lacement
o Order of !lacement in u!!er e/tremityC
Radioce!alic
3asilic trans!osition in forearm
.racioce!alic
.asilic vein trans!osition a.ove el.ow
loo! forearm AV '56B
u!!er arm '56B
o order in ABC
try to use all arms first
S6ALSV loo!
'56B loo!
-at is normal AV6 flowC
total AV6 flows a.ove G00 mlLmin are enoug for dialysis&
o ideally" aim for a flow of c)000 mlLmin&
o minimum flow re>uired is E*0 ccLmin noted on G occasionsLmont
2f an AV6 flow falls .y 2*O or more in any given F monts"
o AV6 e/am wit ultrasound or a fistulogram&
2000 mlLmin is too ig&
US Sign of mature vein
o F mm" Q*00 ccLmin H %*O maturation certainty
o RF mm" R*00ccLmin H EEO maturation certainty
Vein ma!!ingC
Vein , Need 2&* mm .elow el.ow" E mm a.ove
age )2E
Artery H at least 2 mm diameter
Use tourni>uet for vein ma!!ing
2f vein Q * mm dee!" may need to su!erficiali;e it at te later date
?ig radial a& ta:e off may lead to steal in radioce!alic AV6
148.Access options in Central -ein Occlusion:
Recanali;e vein endovascularly
go to lower e/tremity"
o Su!erficial femoral vein trans!osition
o may use KSV if sure no need for lower e/tremity revascularistion in te imminent
future&
KVS vein 0does NO5 dilate muc even if trans!osed to arm1
reconstruction 04ug turn down" .y!ass1
2VC canulation
o !ercutaneous tunneled cateter
o ?eRO device tt!CLLwww&veitsym!osium&orgL!dfLveiL20%0&!df
-eird and -onderfulC
A/,fem,vein !tfe .y!ass as venoud outlflow
A/illary,a/illary artery loo!
3unger" CM $VS 200*" F2021,2%0,2%*
149.Co!plications of A-1 creation:
o 6ailure to mature
o Stenosis 0!articularly at te venous end1
Aeads to trom.osis
Surgery and !ercutaneous trom.olysis e>ually effective
o Aneurismal dilatation
o 3leeding tat can lead toM
'seudoaneurysm
o Seroma tat can lead to M
2nfection
o Steal tat can lead toC
?eart failure
Swelling and Venous y!ertension
Neuro!aty H monomelic neuro!aty
150. &reat!ent of A-1 steal:
age )2F
Some coolness" stiffness and swelling are common after normal AV6 creation& So may want to
wait awile to see if s/s settle&
ReminderC steal a!!ens wit reduced inflow AN# increased outflow resistance in te arm
com!ared to AV6
o #istali;ation of arterial inflow H
for .racioce! AV6" move inflow distally to radial a&
in a way" tis is li:e controlled .anding or creating a smaller inflow
o 'ro/imali;ation of arterial access H
for .racioce! AV6"
move inflow to te a/illary artery&
5is moves !ressure sin: area !ro/imally and
5is im!roves inflow and decreases outflow resistantce to te arm
com!ared to AV6&
o #R2AC
'ro/imila;ation of inflow and increased resistnace to reversed flow
ligate distal to AV6
.y!ass from 2,E cm a.ove AV6 to te !oint .eyond ligation&
o #istal radial a& ligation if rad,ce! AV6C
in a way" a form of #R2A
must ave continuous !almar arc
o Aigate fistula
o 3anding fistula
tt!CLLwww&fistulafirst&orgL!dfsLSurgicaldSalvage&!df
LYMPHEDEMA
151.$y!p" p"ysiology:
Aym! is !ro!elled .y intrinsic contraction of lym! vessels wit directing valves& B/ternal
!ressure as little effect on trans!ort& -it dilation" wen cronic" a.ility to contract is lost& 5is
results in settlement of !rotein ric fluid in te tissues&
152.Classify ly!p"ede!a:
#ifferential diagnosis firstC
AcuteC
o Cellulites
o #V5
o 5rauma
o 6racture
o 5orn ligamentLmuscle
o Ru!tured 3a:er9s cyst
o Acute lim. iscemia
age )2*
Cronic
o AV malformation
o Aym!edema
o CV2
o Systemic disease
C?6
Aow !rotein
Aiver failure
Ne!ritic syndrome
Refle/ sym!atetic dystro!y 0acute stage1
o fat
E(io+ogi% %+assi'i%a(ion-
o 'rimaryC
Congenital R ) yoa
Non,familial
6amilal 0Milroy1 H RoyL:ing .y .irt
'raeco/ ),E* yoa
Non,familial
6amilial 0Meig1 H got my first Mig .efore E*
5arda Q E* yoa
5a,#AX 2 am old nowM
o SecondaryC
6ilariasis
Aym! nodeLvessel in4uryC
surgery
infection
tumor
rads
trauma
Ana(omi% %+assi'i%a(ion-
#istal y!o!lastic 80O 'ro/imal y!o!lastic
)0O
?y!er!lastic )0O
Kender
distri.ution
6emales Any gender Any gender
Aaterality 3ilateral unilateral 3ilateral
onset At !u.erty Any age Congenital
6am / 'ositive No 'ositive
!rogression 3enign" slow course 6ast !rogression 'rogressive
Res!onse to 5J -ell to conservative t/ 'oor to conservative t/
VV
Res!onds to conservative t/
VVV
VV !ro/imal y!er!lastic H May .e candidates for microvascular reconstruction
age )2G
VVV y!er!lastic
mesenteric lym!atics is incom!etent H
reflu/ of cyle and !n losing entero!aty&
Cylous drainage via vagina" scrotum" lower e/tremities&
o May .e treated wit retro!eritoneal e/cision of incom!etent lym!atics&
153.$ong ter! co!plications of $y!p"ede!a:
o AocalC
infection
6i.rosis
Neo!lasia 0lym!agiosarocoma" Stewart,5rives1
o SystemicC
Malnutrition
2mmunodeficiency
154.&reat!ent of ly!p"ede!a:
9ndi%a(ions-
2m!rovement of lim. functionC MOS5 B66BC52VB indication
o severe im!airment of mo.ility
o Reduction of !ain
Cosmetic im!rovement
Reduction of com!lications
o cellulitis" lym!angitis" lym!angiosarcoma
T"ea(men(-
o Conservative
5wo !ases H active decongentstion ten maintenance
elevationLcom!ressionLmanual decongestion
e/cerise
!reventionLtreatment of cellulitis
o !enicillin *00 mg 52# at first sign of infection
.en;o!yrones
o may .e effective in rea.sor.tion and mo.ili;ation of tissue
!ns
com!ressive garment is used for maintaining lim. si;e
o surgeryC R )0 O of all !ts need tis
e/cisional o!erations RARB
o carles
o Ainton , staged su.cutaneous e/cision .eneat fla!s
microsurgical lym!atic reconstrationC V&RARB
o lym!ovenous anastomosis
o lym!atic grafting
age )2+
o free lym!atic fla!
li!osuction
UPPER LIMB
155.7enearl causes of upper li!. isc"e!ia:
2n general" u!!er lim. iscemia is due to s!asm" o.struction" or em.oli&
-en !erforming an angio" always use vasodilators to assess distal s!asm H more
ommonly seen in u!!er tan in lower lim.s&
2f see and wea:ness !ost .racial !uncuture H alsway e/!lore median nerve H small
ematoma in te seat will cause !ermament damage&

o s!asm , ergotamine" 2V drug a.use" raynaude disease
o o.structionC
large vessel H
Aterosclerotic ulcer H more !ro/imal su.lcavian
5OS H more distal su.clavian
Arteritis
o 5a:" KSA
Radiation
6M#"
#2SSBC52ON
small H
C5#
o Scl" RA" SAB" S4o
meta.olic
o #M" CR6
myelo
o trom.ocyto!enia" 'CV" Cold cryglo." y!ercoag"
leu:emia
trauma
o vi.ration" cold in4ury" AV6
oter
o 3urger" intraarterial in4ection" cytoto/ic drugs , cemo
o Bm.oliC
aneu , ventricular" inno" su.cl" a/il" .rac" ulnar
!la>ue , arc" inno"su.clavi
eart , A6" !ost M2" valve
age )28
156.Sy!pto!s 3 signs of &OS:
o 'ain < !arestesia"
o -orse wit arm elevation
o Occi!ital eadace
o -ea:nessLmuscle atro!y 0uncommon1
o Aocal tenderness in scalene triangle
o Blevation Arm 5est 0BAS51 H
wit arm e/ernally rotatedLa.ducted" elevated
can9t re!etitively o!enLclose fist for Q E0,G0 sec
o Adson testC
disa!!earance of radial !ulse wen ead rotated te oter way" .reat in
o 'ositive !rovocative tests seen in normal lim.s as well&
157.Approac" to pt wit" &OS
5OSC
Neuro H %*O
Vein H FO
Artery H )O
OverviewC
Review occu!ation" neurological" arterial" venous" Raynaud sym!toms&
Assess location" laterality" degree of disa.ility&
Review !m/ of com!ressive syndrome" nec:Lsoulder trauma" vi.rationalLoccu!ational
in4ury" C5#" y!ercoag state" A6&
S!ecific ?istoryC
occu!ation" !rovocative maneuvers" and dominance
num.nessLwea:ness 0neurogenic1
ulcersLand fatigueLclaudicationLnail s!linter emorrages 0arterial1
swellingLcatetersLrecent strenuous activity 0venous1
vasomotor sym!toms 0Raynoudes1
.ilaterality
duration"
wat was tried for relief" course of s/s over time"
disa.ility , at wor: and life style limiting
!rev / of
o A6Lanticoagulation
o #V5L?CS
o C5#Larteritis
age )2%
o Central lines
o 5raumaC
Nec:
Rotator cuff tear
?and
Vi.ration
6rost .ite
o ### in nec:
o Bntra!ment
Ulnar
median
medsC OC' if female
fam ?/C y!ercoag state
ROSC functional status" degree of disa.ility&

B/amC
.lood !ressure .ot arms" !ulse >uality
!ulse distri.utionL.ruits
!rovocative testing H
o Adson , radial goes wen ead turned te oter way" .reat in&
o BAS5 , e/ternal rotation" a.duction , can]t sustain fist clincing for more tan E0
sec& ?ig negative !redictive value test&
wasting" wea:ness" sensation" refle/es" 5innel" 'alen test&
Cec: for Rotator cuff tearsLwea:ness" .ici!ital tendonitis
s!linter emorragesLulcersLAllen test&
te rest of e/am , i&e& oter e/tremity" ?S" a.do etc&
wor: u!C
no test alone is indicative or fully diagnostic
go .y !resentation / and !ysical
CJR to cec: for )
st
ri.
o See in )O of !o!ulation" more in women" %*O of arterial 5OS ave it&
#u!!le/ to assess vein and artery
C5A if sus!ect aneurysm
MR2 H .ut may not sow mucM
o -ill rule out cervical dis: disease" syrin/" s!inal cord !ro.lems
Nerve conductions studies are li:ely to .e normal
o 2f a.normal H see median motor and ulnar sensory !ro.lems
Ruterford recommends test in4ection of lidocain in to ASM
o 2f .etter" ten may .enefit from surgery discussion
Surgery is .etter viewed as #2AKNOS52C rater tan tera!eutic
age )E0
158.Co!plications of E
st
ri. resection:
o -ound ematomaLinfection
o 2n4ury to
intercosto.racial n&
.racial !le/us
long toracic n&
toracodorsal n&
!renic n& H tem!orary !alsy seen in )0O of cases
sym!atetic cain
vein
artery
o !neumotora/
o lym! lea:
o !ersistentLrecurrent 5OS
159.Indications for surgery of a su.cla*ian a@ aneurys!:
o Sym!tomaticC
ru!ture"
trom.oem.olism"
!ressureC !ain" .racial !le/us
o Si;e Q 2 cm
o Note tat E0,*0O !ts wit aterosclerotic 0most common ty!e1 aneurysm will ave
aneurysms elsewere
160.-i.ration w"ite finger:
o Raynaud9s !enomenon due to !rolonged use of vi.ratory tools
o Num.ness" tingling ,Q ti!s .lancing !!t9d .y cold
o -it time affected area !rogresses
o Only )O !rogress to ulcerLgangrene
o Mecanism un:nown&
o Cold !rovocation testing diagnostic
o AngioC digital a& occlusion findings
o 5/C avoid cold" may try CC3 for advanced cases&
o Sym!atectomy is RARBA= needed
o 2f digital gangrene H consider !rostoglandin B2Lilo!rost iv
161.Hypot"enar Ha!!er Syndro!e:
o AnatomyC
age )E)
Ulnar aretery over y!otenar imminence is vulnera.le
5erminal .rances or ulnar a& may .e involved 0dee! < su!erficial
!almar1
Arise in te canal of Kuyon& 3oundariesC
Medial H !isiformLoo: of amate
#orsally H transverse car!al lig
Ulnar a& is su!erficial 0s:in" 'almaris .revis1
2ntimal damage H occlusionLaneurysm
?istoC 6M# in media" intimal disru!tion
Raynaud9s !enoemenon" digital iscemia
3ut always s!ares tum. due to radial artery su!!ly
Rarely ulnar a& occlusion
5/C conservative" C#5 if witin 2 wee:s
ResectLre!air ulnar a& aneurysms to !revent em.olism
o 6or graft H arvest distal KSV 0si;e matc1
o Aigate only if !almar arc is !atent
162.Occupational acro)osteolysis:
o 6irst seen in wor:ers e/!osed to !olyvinyl cloride
o Resor!tion of te distal !alange tuft" similar to scleroderma
o Raynaud9s !enomenon
o Angio
digital occlusion AN# y!ervascularity ad4acent to .ony resor!tion
163.At"letic in<uries:
o #igital artery occlusion
5rauma in catcers
Cleland ligamentC from !alan/ to sc tissues" on !almar surface
over '2'
o Bm.oli;ation
Suadrilateral s!ace
o teres minor su!" umerus lat" teres ma4or inf" long ead of
trice!s med
o 'osterior circumfle/ a&" a/illary nerve
o artery !rone to aneurysm in !itcers" volley.all
toracic outlet 0leading to su.clavian aneurysmLtrom.osis1
Lowe LIMB
164.Differential diagnosis of .ilateral lower li!. swelling:
SystemicC MC
o 'itting edema
age )E2
o C?6 H .etter in am after su!ine" .ut may get e/acer.ation of C?6
o CR6 H not .etter in am after su!ine
#rug induced H Adalat H mild
2liofemoral trom.osis
Aorto,caval fistula
Aym!edema
o 5oes H Q groin" s>uaring of toes
o Unilateral most commonly
o ?y!er:eratosis of s:in" fi.rosis at AAS5 stages
CV2 H MOS5 COMMON CAUSB in NA
o Stigmata of CV2
o Almost never involves feet
o 5e only condition to cause scarring of !erimaleolar s:in 0li!odermatosclerosis1
6at legs
165.Approac" to distal peroneal a@
o medial
o !osterior
o lateral wit fi.ula resection
e/!osureC
!eroneal a& is continuation of ti.io!eroneal trun:
MedialC
o in te u!!er calf" 5'5 is e/!osed tusC
s:in" sc fat" !reserve KSV" fascia" divide soleus muscle over angled
dissector" divide anterior ti.ial vein
.eware of dense venous !le/us
o in te middle calfC
muscles of te dee! com!artment
from medial to lateral H
o 6#A H fle/ dig longus"
o 6?A H fle/ al longus"
o '5 H !ost ti.
remove soleus from te edge of ti.ia"
reflect soleus and KC !osteriorlyC
'5 artery is found .etween !osterior surface of te 6#A and soleus H
leave '5 artery in te fasciaLareolar tissue attaced to soleus
Iee! going dee!er
'eroneal a& is found on te !osterior surface of 6?A" close to te
fi.ula&
o #istallyC
6ind !eroneal .etween 6#A and 6?A&
'osterior a!!roacC
o #irect" fewer wound com!lications" for sort .y!ass wit ASV
age )EE
o Su!ine
o 2ncision in distal tird over lateral edge of te calcaneal tendon
o Retract C5 medially and 6?A laterally
Aateral a!!roacC
o )0,)* cm incision
o 2# Common !eroneal n&" !rotect
o Se!arate muscle of lateral com!artment from fi.ula
o B/cise fi.ula" may do so su.!eriosteally" dril in !laces of resection for clean
cut
o 'eroneal a& is Sitting rigt tere in te fi.ular .ed&
166.1ate of a claudicant:
, 2N KBNBRAA" 20O deteriorate" )0O CA2" 2O lose lim.s 0more if dia.etic1&
, #ecrease in A32 R 0&* is .est !redictor of deterioration in 2C and mortality
, At * yearsC
CV MOR32#25= 0non,fatal M2 or stro:e1 20O
CV MOR5AA25= )0,)*O&
Ris= o' +imb +oss in 9F %an be s("a(i'ied- !& )G" Ruterford
o 2t is too sim!listic to say for all 2C ris: of lim. loss is )O !er year
As is suggested .y B'2#BM2OAOK2C data from 6ramingam
o 9' %+ini%a++$ %on'i"med, "is= o' L9M< +oss is %+ose" (o MK 5e" $ea"
E&+O if diagnosis is esta.lised clinically
*&8O if diagnosis confirmed wit non,invasive studies
8&* O if A32 .etween 0&F,0&G
?ence term su.critical iscemia
age )EF
6rom 5ASC 22C
2ntermittent claudication No intermittent claudication
* year survival 8*O %*O
)0 year survival *0O 8*O
A32 R0&* is an im!ortant !redictor of overall survival&
F+audi%a(ion managemen( o5(ions-
Krade it first H wit treadmill& Ma/imum -al:ing #istance is MORB !redictive tan 'ain 6ree
-al:ing #istance&
A32 is te .est !redictor of a..revitated survival&
KoalC
2ncrease >uality of life
increase 'ain 6ree -al:ing #istance" and Ma/imum -al:ing distance
o cilasta;ole
o wal:ing e/ercise
delay !rogression to CA2
o modification of R6
5oroug discussion reC natural / of claudication&
)& 3enign H 20O worse" )0O CA2" 2O lim. loss
)& See a.ove H may .e as ig as 8O !er year&&
2& Overall felt NO5 to .e a lim. treatening issue
2& 'ro.lem is glo.alC need to address all vascular .eds
)& i&e& !ain in te leg is Aife style issue
Managemen( o' "is= 'a%(o"s-
age )E*
interestingly enoug" tis will not affect claudication distanceM
o success in slowing te !rogreesion of 'A# and im!roving 2C has not been
proved .y statistically significant valid clinical trials& Ruterford '& G02
.ut it ,i++ add"ess (he g+oba+ 5"og"ession o' a(he"os%+eo"isM
o as .een sown to reduce te ris: of CA# and !rogression to CA2
S!ecifically" wat needs to .e doneC
Smo:ing cessation
o Smo:ing im!roves 2C distance in some .ut not oter studies" ence no consensus
o Cessation will im!rove !atency of .y!ass E foldM
o ))O of smo:ers wit 2C will undergo am!utation" com!ared to 0O in non,
smo:ers
o E fold iger ris: of needing intervention if !t as F0 !ac: year of Smo:ing
?5N control
?A control
o Reduces !rogression to CA2
#M if !resent
o 5reatment of #M was NO5 sown to reduce am!utationsM
Anti!latelet medications
Wa+=ing (he"a5$- (he on+$ non/o5e"a(i&e ("ea(men( sho,n (o im5"o&e
9F8
Su!ervised .etter tan non,su!ervised
)*0 m difference" Cocrane" 200G
E0 minLE times a wee: for E monts"
increase to G0 min a session
increase s!eed from 2 miL to E miL
initial goal )0 min !ain free wal:ing ten start !using
im!rovements in wal:ing efficiency" endotelial function and
meta.olic ada!tations in s:eletal muscle
Cocrane meta,analysisC
)*0O increase in M-#
o #RUKSC
o Cilosta;oleC
decreased !latelet aggregation < 5K" increased SMC rela/ation <
?#A meta.olism
A.out )F0 m 0F*0 f1
Ruterford1" 5a:s 22 H *0,+0 m&&&
E0,)00O M-#
Mc side effectC eadace" diarrea
o 'ento/yfyllineC reologic drug
age )EG
Some studies sow .enefit" oters don9t
'lace.o vs drugC 2FO vs F0O in '6-#
E2O vs 20O in M-#
Overall li:ely small im!rovementC *0m 0)G0 f1
o O!erative interventionC .y!ass vs '5A&
RC5C wal:ing vs endovascular" 200%
+G !ts BN#O vs +* !ts wal:ing tera!y
?os!ital .ased
'roven mild" moderate and severe Claudicants
Measure 6unctional ca!acity" M-#" '6-#" A32 im!rovement over )2 monts
2m!rovement in wal:ingC
1 ,ee= A mon(hs 13 mon(hs
Bndo )st 88O +*O G8O
-al:ing )GO ++O G*O
B>uivalent o.4ective and su.4ective im!rovement .etween two tera!iesM
Bndovascular tera!y does no( %"ea(e ne, indi%a(ions for an intervention&
2t defines a !o!ulation wit an acce!ted indication tat allows acce!ta.le im!roved outcome
wit lesser intervention&
2deal tecnical outcome of an o!en .y!assC
o !atency" lim. salvage and survival
o seen in a( +eas( N0K o' b$5asses
9dea+ 'un%(iona+ ou(%ome a'(e" an o5en b$5ass-
o ?os!ital free life" reintervention" wound ealing" significant cange in
AM3UAA5OR= !otential
o seen in on+$ 1MK o' a++ b$5asses:
CAN#2#A5BS 6OR BN#OVASCUAAR 2N6RA2NKU2NAA 5?BRA'=C
o Bconomic claudicants
e/austed conservative trial of R6M" wal:ing" and cilasta;ole and
wo understand tatC
intervention is done for Aife style issues" not lim. salvage
com!ared to o!en intervention" '5A offers an uncertain .ut
reasona.le dura.ility
com!ared to o!en intervention" '5A carries SMAAABR cance of
conversion to CA2 and lim. salvage situation
age )E+
o !atients wit CA2 wit non,!roi.itive tissue loss AN# limited !reo! am.ulatory
ca!acity
des!ite an e/cellent antici!ated 5BC?N2CAA outcomes of te o!en
.y!ass in te end are !redicted to ave su.o!timal 6UNC52ONAA
outcome
.ased on teir fea.le ealt status" nursing ome situation" !oor
!remor.id am.ulation&
2n tese su.selected cases" minimal intervention tat converts CA2 0rest
!ain or ulcer1 to claudication status is wortwile&
o S2A as a 5ecnical ad4unct to o!en a!!roac allowing for !erformance of y.rid
cases wen !urely o!en a!!roac is eiter im!ossi.le or im!racticalC
5ASC 22" 3 ty!e S6A lesion
sort conduit , S6AL!o! inflow source management
C6BA o!en and S6A angio
2f claudicants re!resent )*O of te o!erated u!on !o!lution" ten i]d a;ard *O would to .e tas:
A and 3" and ence candidate for endo first o!tion& As far as te CA2 it is ard to !redict te
num.ers&&& E0OD
167.C$I criteria:
o Severe R' re>uiring o!iate analgesics for QF wee:s and eiter
Ulcer
An:le !ressure R F0 mm ?g
5oe !ressure RE0 mm ?g
age )E8
168.(atural "x of pts wit" C$I:
CA2 at diagnosisC
o *0O receive revascularisation
o 2*O are given conservative t/
o 2*O receive !rimary am!utations
At ) yearC
o 2*O CA2 resolved
o 20O ongoing CA2
o E0O are AA2VB .ut am!utated
o 2*O dead
Note" tat !ros!ect of lim. loss is not universal& -it conservative management" *0O will :ee!
teir lim. and F0O of ulcers will eal&
169.&ASC classification for iliac and S1A lesions:
o 9+ia%- need to :now only A and 3 H as tese are te for endo" te rest is o!enM
A
C2A stenosisC uni or .ilateral
B2A stenosis RE cmC uni or .ilateral
3
R E cm aortic stenosis
Unilateral C2A occlusion
Unilateral B2A occlusion
o Not involving 22A or C6A
C
age )E%
.Ll C2A occlusion
.Ll B2A stenosis not e/tending into C6A E,)0 cm
uni B2A stenosis e/tending into C6A
#
2nfrarenal occlusion
Aortic Aneurysm
Uni stenosis of .ot C2ALB2A
.Ll occlusion of B2A
o ;DA
A
Single stenosis R)0 cm
Single occlusion R* cm
3
Multi!le stenosisLocclusion R *cm eac
R * cm calcified
Single stenosis R )* cm" not involving !o!
;ing+e o' mu+(i5+e +esions in (he absen%e o' %on(inuous (ibia+
&esse+ in&o+&emen(
o To im5"o&e in'+o, 'o" dis(a+ b$5ass
C
Multi!le stenosisLocclusion Q)* cm
Recurrent stenosisLocclusion after 2 endo treatments
#
Bntire S6A occluded
'o! or trifurcation occlusion
170.,ASI$ study:
Randomi;ed !ros!ective trial
2+ UI os!itals
F*0 !ts wit CA2 were randomi;ed
3y!ass vs '5A as )
st
treatment wit CA2 due to infra,inguinal disease
Crossover of !atients was allowed after randomi;ation
5wo strategies 7.roadly similar8 wrt
o am!utation free survival"
o all,cause mortality
o >uality of life in te S?OR5 term&
o Surgery )LE more e/!ensive
Ia!lan,Meier !lots for long termC
o am!utation free survival and all cause mortality favour '5A )
st
for te first 2
years"
o .y!ass was .etter !ast 2 years&
Overall" at te end of E years"
o ;u"ge"$ 2 MLK am5u(a(ion '"ee su"&i&a+
age )F0
o .TA 2 M3K am5u(a(ion '"ee su"&i&a+
o )&e"a++ +onge&i($ / M0K
Hen%e, i' +i'e e75e%(an%$ is +ess (han 3 $ea"s, o''e" .TA8
9' +i'e e75e%(an%$ mo"e (han 3 $ea"s, o''e" su"ge"$ 8
171.-ein ad*antages o*er prost"etic:
Com.ines many of te ideal >ualities of te graftM
o 3iocom!ati.le
Resists trom.osis
B/cellent ingrowt
Aess infecta.le
?eals if infected
dura.le
o similar to native .io!ysical matcC
im!ermia.le
3etter si;e matc
Com!liance similar
Krows wit arterial system
o Aogistical
Cea!
Availa.le
Basy to andle
As a "esu+(, &ein has be((e" 5a(en%$
172.Options for .ypass graft !aterial in descending order of
preference:
o KSV
o ASV
o Arm vein
o Com!osite graft 0wit ad4uncts H venous cuffL!atc1
#o not do straigt !tfe,vein anastomosis
Rater" !tfe goes to .lind arterial segmentLdistal S6A
Vein ta:es of distal to te !tfe" NO5 off te ood of te !rostetic
.y!ass
o SV6
o 'rostetic 0e!arin .oundQ'56B" #acron1
o Cadaver KSV
Cryo!reserved
) year !atency 28,80O
2 year !atency )%,F0O
age )F)
Barly failure )+O
Aate aneurysm *,E0O
Aim. salvage G0,)00O
'&+20,2)
o Allogenic veinLartery
NoteC
in tig and calf" G*O of KSV is single" E*O , dou.le system
most common location of a..erantly !laced KSV is AN5BRO,AA5BRAA to
usual location&
Cryo!reserved veins are NO5 .etter tan a./ .onded graft in infected field
wrt !atency\
According to Ruterford9s Com!anion" ?UV is 3B55BR tan multis!liced
vein for distal .y!ass& 2t also as same rate of infection as autologous vein&
?UV as outer su!!orting mes and needs s!ecial andling&
Antiocoagulation" cuff !atc will im!rove !atency of 3I !rostetic .y!ass
173.Synt"etic grafts + c"aracteristics:
o woven
long 0war!1 and circumferencial 0weft1 tread !attern
low !orosity
strong
stiff
doesn9t dilate
!oor andling" fray at edges
recommended for ru!tures and toracic re!lacement
o :nitted
!redominantly long 0war! H long way from ome" Star5re:1
lea:s H need !reclotting
fle/i.le" comforta.le
dilates wit time
o veloure
micro loo!s on te outside
designed to im!rove incor!oration into tissues and !rotein
adesion H to reduce !orocity&
o Irim!ing
adds fle/i.ility and elasticity
may interfere wit laminar flow
smaller diameter may cause increase trom.ogenicity
o .iologic coating
age )F2
wit al.umine
to im!rove !orocity issue
more e/!ensiveM
saves time H no need to !reclot
Bndotelial seedingC
still e/!erimental
do not decrease anastomotic y!er!lasia
owever" sow .etter !atency at E years
only F0O of attaced cells remain on graft at 2F
174.Ad*erse effects of -ein "ar*est:
o #issection tecni>ue H trauma to vessel wall" tying .rances too close
o 6orceful dilation H :ee! under 200 mm ?g" oterwise will sloug endoteliumN
2t leads to in4ured vessel wall tat will aveC
o Aeu:ocyte infiltration
o intimal tic:ing via intimal y!er!lasia
neointima" SMC ingrowt in intima" intimal matri/
de!osition
o su.intimal fi.rosis
Bndotelial disru!tion leads to te following effectsC
loss of fi.irinolityc a.ility
increased A#A u!ta:e
loss of NOL!rostocyclin secretion
o 5em!erature H conflicting
E+ degrees C vs 2,F"
less !rostocyclin < NO syntesis su!!ression wit room storageM
Ruterfords com!anion recommends COA#
o SolutionC
-arm wole .lood .etter tan cold crystalloid&
'a!averin !revents vasos!asm
?enceC gentle dissection" under 200 mm" e!arini;ed cold saline wit !a!averine
175.xpected patency of *ascular grafts 3 procedures:
9+ia% angio5+as($-
2222 lim.s
+GO claudicannt
) year H 8*O
* year H +0O
;DA 2 5oo+ed "esu+(s- TA;F 99
age )FE
) year E year * year
'5AC stenosis +*O G0O **O
'5A P stentC stenosis +*O G*O ,
'5AC occlusion G*O *0O F0O
'5A P stentC occlusion +0O G*O ,
i&e& stent offered a.out *O im!rovement
M $ea" 'em 5o5-
Claudicant CA2
Vein 80O G*O
AI '56B +*O *0O
3I '56B G*O G*O
2 am !u;;led as to wy 5ASC 22 offers no e/!lanation for !atency for 3I '56B .eing e>ual for
claudicants and CA2M
A@ .TDE &s &ein- se&e"a+ RTF ana+$sis, a( M $ea"s 2 TA;F 99 "esu+(s
Vein +*O
'56B *0O 0o!timistic1
5ere is NO dou.t tat A3SOAU5B !atency of AI vein graft is su!erior to '56BM
Classic Veit RC5 studyC
F year results vein '56B Stat significance
3elow :nee G8O F+O 0&02*
A.ove :nee G)O E8O 083M 6J;#
Comment H low num.ers" .ut trend was toward vein su!eriorty in a.ove :neeM
VA .oston study" 2000
AI location" no #M" no women
* year results
2n tis study" ?US was used as well and did .etter tan '56BM
(J Vasc Surg 2000;32:268-77.)
claudication CA2
Vein 80O G8O
'56B EEO E+O
Ilinert" 200F Metaanalysis
At F years" tere is 20O difference .etween vein and '56B
Selected F >uality RC5
G%O vs F%O in favor of vein&
age )FF
NO5BC 200% Cocrane analysis on AI vs 3I veinL'56B is USBABSS H no recommendation
given" studies are !oor" etc& #one .y te RN" not M#& ?eavy criticism of tis study at 200%
?arvard Review course&
Aim. .ased * year )0 year
Aorto.ifemoralC claudication %0O 8*O
Aorto .ifemoralC critical lim. iscemia %0O 80O
A/illo,uni *0O
A/illo,.i,fem +0O
6em,fem +*O
)%%% metaanalysisC
2m!rovement in !atency of !rostetic grafts 0.ut not autogenous1 wit anti!latelet t/&
* year !atency according to 5ASC 22C
%0O grou!C
o Aorto,.i,fem
+0O grou!C
o 6em,fem
o 6em,!o! 3I vein
o 2liac,'5A
o A/,.ifem
*0,**O grou!C
o A/,unifem
o S6A angio!lasty for stenosis
age )F*
F0O grou!C
o S6A angio!lasty for occlusion
o 6em,distal .y!ass
E0O grou!C
o 6em,!o!,3I !rostet
Oter info re !atencyC O'BN S6A 3='ASS RBSUA5S according to 5ASC 22
Claudicant CA2
Vein 80O G*O
AI '56B +*O *0O
3I '56B G*O G*O
Results of S6A endovascular !atency according to 5ASC 22" cumulative
) year E year * year
'5AC stenosis +*O G0O **O
'5A P stentC stenosis +*O G*O ,
'5AC occlusion G*O *0O F0O
'5A P stentC occlusion +0O G*O ,
176.Co!plications after infrainguinal re*asculari>ation:

age )FG
BSR# is s!ecial caseC for infrainguinal .y!assM&
BSR# wit BSR# CA2 wit NO BSR#
'erio!arative mortality *,)0O 2,EO
Survival *0O at E years *0O at * years
-ound < incision ealing 'oor 3etter
5ose wo !ersue aggressive indiscriminate revasculari;ation of tese !ts are not !racticing
evidenced .ased medicine& 0Ruterford1
AS2#BC
Cryo!reserved vein for infrainguinal .y!assC
) year !atency H 28,80O
2 year !atency H )%,F2O
Barly failure H )+O
Aate aneurysm H *,E0O
Aim. salvage H G0,)00O
So !atency rates are NO5 sterling" so ma:e your own conclusions&
age )F+
177.7raft sur*eilance:
)*,20O of graft fail witin * years
o )0 O , see failure in first E0 daysC
'oor >uality vein
'oor anastomosis
'oor outflowLinflow
9n u5 (o A0K o' ea+$ 'ai+u"e a"e due (o g"a'( +esions
o 'oor vein vs valve vs twist vs anastomotic narrowing
Te%hni%a+ e""o"s "es5onsib+e 'o" 4/3MK g"a'( 'ai+u"es
A( e75+o"a(ion, M0K o' g"a'(s ha&e no a55a"en( 5"ob+ems8
6ailure in first 2 yearsC
o Mostly due to intimal y!er!lasia
25 is critical to detect failing graftC
Most veins don9t stay o!en after mecanical trom.ectomy or trom.olysis
o 'atency after trom.olysis is 20O at ) year
o At ) year"
*0O are am!utated"
2*O ave rest !ain"
)*O deadM
3ut lim. salvage may .e .etter
o Surgery is a .eter o!tion ifC
5a:en to OR immediately
Mecanical !ro.lem is detected 0twist" valve cus!1
5raditional ways to detect failing graft lac: sensitivity
o Recurrent sym!toms
o AossLreduction of !ules
o A32 cange of Q 0&2
''V )2,EFO" i&e& AO-
8O of lesions develo! in first year
o Aesions develo!ing in first E monts are more treatening tan late ones
5ere is 2,FOLyear late graft stenosis 2N A##252ON to )0O life time ris: of
!rogression of aterosclerosis&
6irst surveylance du!le/ studyC at discarge or ) mont"
o ten .iannually for 2 years"
o ten annually for life
Cec: KV6" 'SV in te lesion& Krade ris: level&
Revise grafts at ig ris:
age )F8
R9;@
LEGEL
H9IH/GEL)F9TT
FR9TER9A
L)W/GEL)F9TT
FR9TER9A
A<9
REDHFT9)J
?igest 'SV Q E00 cmLsec or Vr Q
E&*
Or B#V Q )00 cmLsec
and K6V R F* cmLsec or Q0&)*
?ig 'SV Q E00 cmLsec or Vr Q
E&*
and K6V Q F* cmLsec and R0&)*
2ntermediate 'SV )80,E00 cmLsec or
Vr Q 2&0
and K6V Q F* cmLsec and R0&)*
Aow 'SV R )80 cmLsec and K6V Q F* cmLsec and Q0&)*
A32" an:le,.racial inde/N 'SV" !ea: systolic velocityN Vr" ratio of te 'SV witin te lesion to
te 'SV in a !ro/imal normal segment of te graftN K6V" graft flow velocityN B#V" end,diastolic
velocity&
Krafts at ris:C tese need angio and li:ely revisionM&
o low,flow velocities in te graft
!ea: systolic velocity R F* cmLsec trougout te graft
o 'SV Q E00" B#V Q )00
5ese need to undergo angiogra!yC
o d"o5 in A<9 e7%eeding 081M in (he absen%e o' de(e%(ab+e g"a'( +esions
need arteriogra!y to searc for inflow" outflow" or missed graft lesions
Krafts wit low and intermediate ris: H followC > E monts
o *0O of tese will !rogress&
Vein graft surveillance im!roves long,term vein graft !atency .y a!!ro/imately )*O
RC5 .y Aundel" multi!le o.servational studies
Cost effective 0multi!le studies1
2n general" o!en re!air wit !atc or inter!osition gives .est results&
178.Iliac P&A + risks of procedure:
o #issection
o Ru!ture
o #istal em.olisation
o 5rom.osis
o Restenosis
o 6alse aneurysm
o 2nfection 0if use stent1
179.Pri!ary and secondary patency:
age )F%
'rimary H
o O of grafts tat remain !atent" witout failure" over a given time
o 2ncludes grafts tat were rescued 'R2OR to occlusion 0assisted )
o
!atency1
Secondary ,
o O of grafts tat remain !atent A65BR it was restored following failure
o #oes NO5 include !rocedures wen new graft is inserted
Li'e (ab+e me(hod-
Can .e used for data sets MORB tan E0 !ts only
2nitially used to measure survival of cancer !ts and effect of tera!eutic intervention
Bvents 0graft failures1 are grou!ed into intervals
Survival is ten calculated for eac interval
Ma4or assum!tionC
o all witdrawals occur in te middle of te interval
o failure rate is sta.le over te interval duration
6ailure rateU num.er of failuresL0num.er at ris: H e num.er of witdrawals1
Curves are straigt lines" not ste!s
2nformation needed for life ta.leC
o 2nterval !eriod
o Num.er of !ts at ris: for eac interval
o Num.er of !ts witdrawn !er interval
o Num.er of failures !er interval
Cumulative !atency
o Cumulative !atency for )
st
interval U Success rate U ) H failure rate
o Cumulative !atency of te 2
nd
interval U success rate for )
st
interval J success rate
for 2
nd
interval
@a5+an/Meie" Me(hod-
'roduct,limit metod
#ate is not grou!ed in intervals
o Or interval are very small and contain only one o.servation !oint
Bvent occur at individual failure !oints
No corrections are needed for witdrawals
Kra!ically re!resented as stair Hcases
o 3etween events" noting is :nown a.out te failure rate H it is assumed to .e 0M
A!!ro!ritate for AN= data si;e
Com!arison .etween !atencyC use log,ran: test of significance
age )*0
180.&ests for e*aluation of t"e donor iliac artery prior to fe!)fe!:
o 'al!ation of fem !ulse
o 5ig,.racial inde/
o 5ig !letysmogra!y H .ris: u!stro:e and good e/cursion
o #u!le/ of iliac H
5ri!asic
No 'SV elevation
S!ectral window !reservation
o 32'AANAR angiogra!y H evidence of anatomic stenosis
2f >uestiona.le lesion H wal:ing A32 or angio wit vasodilation
o #irect 6em artery !ressure measurement
Normal H less tan * mm ?g gradient wit CA side
Normal H less tan )*O dro! wit vasodilation
181.Popliteal aneurys!:
o Male" elderly !ts H G,+
t
decade
o *0,+0O are .ilateral
o E0O ave AAA
o E0O ave fem Aneu
o F0O involve ti.L!er trun:
o ClassificationC
6usiform vs saccular
'ro/" mid" distal
o Asym!tomatic in E+O
o 2f sym!tomaticC
2scemic 0!rogressive em.oli;ation" trom.osis1 H **O
Aocal effect GO
'o! mass
'ain
Venous com!ressionLedemaL!le.itis
Ru!ture )&FO
o -en to fi/C
All sym!tomatic
Asym!tomatic Q 2 cm
o ORC
Bndo vs o!en
Single small RC5 sowed e>uivalence of results
Antonello" 200+ u!date
)5en 3L 5(s Endo 31 5(s 5
age )*)
)2 monts
)f )00O 8G&+O NS
2f )00O )00O NS
+2 monts
)f +)&FO 88&)O NS
2f 88&)*O 8*&%O NS
O!enC
Medial vs !osterior a!!roac
?uang" 200+" F year
o 'rimary !atency 8*O 0vein1" *0O 0!tfe1
o Secondary !atency %FO 0vein1 vs GEO 0!tfe1
Consider intrao!erative trom.olysisLisolated lim. !erfusion
2f elective" R)O mortality and lim. loss
2f emergent *O mortality and u! to 20O lim. loss
26 see .ot AAA and !o!liteal H fi/ !o!liteal aneurysm first H oterwise ris: trom.osis in
!erio! !eriod& 0Ruterford1
182.Approac"es to pop aneurys! repair: ad*antages and
disad*antages
MedialC
A#VAN5AKBSC
easy KSV arvest"
su!ineLnot !rone !osition H easier for KA" no ris: for retinal iscemia
familiar a!!roac"
can get far remote and distal access to S6ALtrifurcation
avoid ti.L!eroneal nerves
#2SA#VAN5AKBSC
Sa!enous n& in4ury
#ifficult to get into aneurysm
Aong scar
'osteriorC
A#VAN5AKBS
Basy access to aneurysm H ligate all te feeding .rances
Basy way to decom!ress aneurysm
Can do inter!osition re!air
Basy access to ASV
Can go furter distally H 4ust s!lit te gastrocnemius
age )*2
Smaller cosmetic incision
#2SA#VAN5AKBSN
Unfamiliar territory
'o! vein and ti.L!er nerves in te way H in4ury !otential
Can9t go far !ro/imal
Can9t easily get KSV
'rone !osition H more difficult to KA 0ris: to eyes and airway loss1
-ound ealing !ro.lem
183.7oals of perip"eral aneurys! treat!ent:
o Bliminate source of ateroem.olismLtrom.osisLru!ture
o Bliminate mass effect
o Maintain distal !erfusion
o 'revent recurrence
184.(er*es encountered in popliteal a@ exposure:
o 5i.ial
o Medial sural H off ti.ial
o Common !eroneal
o Aateral sural , off common !eroneal
o Medial receives a .ranc off lateral .ranc" and from median 0lesser1 sa!eous
nerve
AsideC
Sa!enous n& H medial calfLfoot
Sural n& H lateral foot
Su!erficial !eroneal H foot dorsum
#ee! !eroneal H )
st
we.
5i.ial H !lantar surface
185.Cystic ad*entitial disease:
o Mucinous cystLgangion in te arterial wall
o Mc location !o!liteal"
Second most common site , B2A
Also seen in C6A" radialLulnar" KSV at S6$
o Male more common tan female
o 5eoriesC
Origion form Kanglion H
o Since lesions are seen near te 4oint
re!etitive trauma
age )*E
systemic disorder
develo!mental H te most !lausi.le teory of all
o inclusion of mesencymal mucin secreting cells in adventitia
during a.errant em.ryonic develo!ment
o NoteC a!art from develo!mental" tere is no su!!ort to te teories !resented ere
o 5reatmentC
cystotomy , cyst evacuation 0NO5 resection1
o!en , 3BS5 com!ared to !ercutaneous
re!lacement if trom.usLfi.rosisLaneu
186. Angio findings in ad*entitial cystic disease
o Smoot ta!ering stenosis
concentric cyst H our glass a!!earance
eccentric cyst H scimitar sign
o arterial occlusion 0seen later1
o 'ro/imal artery free from aterosclerosis
187.Causes of popliteal a@ occlusion in order of fre2uency@
o 'ro/imal sourceC
Bm.olus
Aortic dissection
o Aocal sourceC
5rom.osis of ateroscleoritic lesion
Aneurysm
2n old H degenerative AAA
2n young H tin: infected aneurysm 02V drug use1
'o! entra!ment
Cystic adventitial disease
5rauma 0:nee surgery" disarticulation1
6M#
3uerger9s
'seudo/antoma elasticum
'ersistent sciatic artery
188.&ypes of popliteal entrap!ent:
o normally !o! a& goes .etween eads of gastroc 0?OK1&
o 5y!e ) H !o!& a& lies a.normallyC medial to normally !laced medial ?OK
NO5 te most fre>uent ty!e
o 5y!e 2 H !o!& a& is com!ressed .y A.normally 0more laterally1 !laced ?OK
age )*F
o 5y!e E H !o!& in normal !osition" com!ressed .y a.normal lateral sli! of
muscleLtendon
o 5y!e F , !o! a& is com!ressed as it runs dee! to !o!liteus muscle
o 5y!e * H any ty!e 'AUS !o! vein PL, ti.ial n& involvement
Vein is involved in )LE of cases
o 5y!e G H functional H i&e& no a.normality is identified .ut !o! artery is com!ressed
in certain !ositions
-en e/amining" ma:e sureC
Ascertain a.sence of aterosclerosis R6 and vasculitisC
o ?5N" #M" ?A" smo:ing" 6? of !remature asc" omocysteinmeia
B/amine contralateral e/tremity
age )**
Bvaluate arterial" venous and neurologic status
Cec: out !ulses during stress testC tensing of te gastroc
o 'assive dorsifle/ion
o Active !lantarfle/ion
NoteC stress test is !ositive in )LE of normal individuals
Angio findingsC
o Medial deviation of !o! artery
o Mid !o! segmental occlusion 0wit stress1
o 'ost,stenotic dilatation
All !ts wit ty!e ),* sould .e fi/ed H !rogress to occlusionLaneurysm
6or ty!e G H indications is less clearM
o may .e entra!!ed .y sligtly mal!ostioned soleusLmedial ?OK
o may consider division of te muscle ead if no oter e/!lanations of s/s&
Resect artery ifC fi.rosis" aneurysm" trom.us on intimal surface
189.Causes of early li!. ede!a after a fe!oro)ti.ial 7S- .ypass
o At one year" )0,20O
o #isru!tion of lym!atics 0most im!ortant1
Blevate" com!ression dressing
o Surgical trauma H inflam res!onse" increased 26 accumulation
o Venous interru!tion
Not a contri.uting factor unless tere is
o #V incom!etence
o #V5
190.Causes of co!part!ent syndro!e:
o #efinition of Com!artment syndromeC
'ressure increase in te constrained s!ace"
Most commonly due to interstitial fluid swelling
CausesC
o Restricted com!artment volumeC
Casts
Constrictive dressing
MAS5
Circumferencial escar
o 2ncreased volume of com!artmentC
S!ace occu!ying lesions
o ?ematoma
o A.scess
o Synovial fluid 0ru!tured 3a:er9s cyst
o 2nadvertent infusion of crystalloid
age )*G
Swelling of soft tissue" !rimarily muscle
o 2scemia,re!erfusion in4ury
o Venous outflow o.struction
o 5rauma
o Ris: factors for CSC
QG iscemia
Com.ined vein and artery trauma
'articularly if accom!anied .y vein ligation
'o!liteal artery in4ury
Massive soft tissue in4ury
S/sC
)& !ain out of !ro!ortion to te !ysical findings" getting worse
2& distal motorLsensory dysfunction according to com!artment
a& wea:ness of dorsifle/ion and num.ness of )
st
dorsal we. s!ace in AB
.& wea:ness in wrist e/tension and num.ness in )
st
we. s!ace in UB
E& muscle !ain" worse wit !assive fle/ionLe/tension
Arterial !erfusion !ressue H gradient .etween MA' and interstitial !ressure&
2ntervention is recommended wen com!artment !ressure is witin 20 mm ?g of
te diastolic or E0 mm ?g of te MA' for Q F ours&
A.solute num.ers are generally misleadingM
2ndirect test to RUAB OU5 CSC
do #US of te veins in te affected com!artment H !reservation of normal
res!iratory !asicity will rLo CSM !&)0G)
o legs H flow augmented wit e/!iration and ini.ited wit ins!iration
o arms H te o!!osite
5/C
Barly recognitionC
F com!artment fasciotomy in lower e/tremity
U!!er e/tremity Curvilinear volar incision
antecu.ital fossa,Q!alm" o!en u! Car!al tunnel
Oter !laces H longitudinal over involved com!artement
B&g& over dorsum of metacar!alLmetatarsal .ones
AsideC
%h"oni% %om5a"(men( s$nd"ome H re!eatative lower e/tremity anterior
com!artment 0most common1 !ain wit minimal e/ertion&
Normal circulation&
age )*+
#s H tenderness over com!artment and loss res!iratory !asicity of veins in te
com!artment&
5/C cosmetic incision and fasciotomy curative&
191.Calf co!part!ents:
AnteriorC 5A" B?A" B#" 'eroneus tertius" dee! !erineal n&
AateralC 'eroneus 3revisLAongus
'ost #ee!C 5'" 6?A" 6#" !o!liteal" ti.ial n&
'ost su!erC KC" Soleus" !lantaris
192.Acute li!. isc"e!ia classification:
o Category )C
via.le" no motorLsensory loss" arterial #o!!ler !resent
may do angio
o Category 2aC
marginally treatened" mild sensory loss" no motor loss" no arterial
#o!!ler signal" venous #o!!ler !resent
may do angio" .ut consider surgery soon
o Category 2.C
immediately treatened" mild motorLsensory loss
ave to go to OR" angio on ta.le if needed
o Category EC
irreversi.le" anestetic" !aralytic" no arterial AN# venous #o!!ler&
5oo late" am!utation
Signs suggestive of irreversi.le lossC
)& 6i/ed cyanosis
2& Mar.led mottling
E& MyositisC doug consistency" calf !ain" muscle rigidity
F& Anestetic sensory loss
*& Com!lete !aralysis
G& No s!ontaneous venous do!!ler
193.A!putation le*el and .ones:
3IA H ti.Lfi.
Syme H distal ti.Lfi." 0&* cm !ro/ to an:le 4oint
Aisfranc H forefoot disarticulation at tarsal,metatarsal 4oint
Co!art H midtrasal disarticulation H at talo,navicular 4oint
194.Define different types of a!putations:
6ailed infrainguinal revasculari;ation will NO5 affect level of am!utation" nor will it increase
!erio!erative am!utation mortality& ?owever" it may !rolong wound ealing and long term
survival of te !t&
age )*8
o 5oe H
OM" neuro!aty confined to distalLmid !alan/"
fismout incision" !reserve small .utton of !ro/ !alange over
M5 ead"
no !rostesis needed
o Ray H
locali;ed gangreneLinfection to M5' crease or involving ead"
rac>uet incision" divide nec: at F* degree !lantar .evel"
ortotic may im!rove .alanceLminimi;e s:in trauma
o 5MA H
total !lantar fla!"
gangreneLiscemia of multi!le toes s!aring !lantar s:in
may need to modify soe wit steel san: to allow normal 7toe8
!us off and !revent e/cess dorsifle/ion
o 3IA H
2N#2CA52ONC KangreneLinfectionLunreconstructa.le R'Lnon,
ealing ulceration and CAN95 do more distal am!utation&
MC !osteriorly .ased myocutaneous fla! on KC and Soleus
muscles&
Need !rostesis& F0O energy increase" E0,+0O am.ulate again
o Inee disarticulation H
occasional use"
o if good .lood su!!ly" .ut as contracture or can9t do 3IA&
#ifficult !rostesis&
5y!es of fla!sC
o Aong anterior"
o e>ual ant < !ost"
o e>ual med < lat fla!s&
Condyles H must .e transected to allow !rostesis
o AIA ,
in .ed ridden"
KangreneLinfectionLunreconstructa.le R'Lnon,ealing ulceration
and CAN95 do more distal am!utation
fis mot" ant < !ost fla!
te longer te saft" te .etter te am.ulation !otential
u! to *0,+0O energy increase
)0,E0O am.ulate
o ?i! disarticulation 0rarely !erformed1
o AsideC
age )*%
6inger am!utations are .etter dealt wit .y !lastic surgeon
Re!lant may not .e as functional as am!utation
One study" sowed %0O e/cellent functional outcome wit finger
am!utation vs FFO wit re!lant
?aving said tis" do not rus to ray am!utation H it will decrease gri!
strengt and a.ility to su!inate&
195.&ests to use to select le*el of a!putation:
2n general ratio of AIA vs 3IA is )to )
o ClinicalC
QG0 mm an:le H o: for 3IA
Accuaracy *0,%0O 2&e& could .e a coin tossX
Q F0 mm toe H o: for 3IA
o Angiogra!y 0!oor1
o S:in tem! Q %06
o Segmental and toe !ressure
o 5ranscutaneous o/ygen saturation 0most accurate1
R E0 mm ?g" !ro.a.ly o:
o 2ntradermal isoto!e .lood flow
o OterC
S:in fluorescence < Aaser #o!!ler
S:in !erfusion !ressure
196.Co!plication of .elow knee a!putation:
5ASC 22
o SystemicC
#eat
Barly )0O for 3IA")*O for AIA
o BSR#" se!sis" acute iscemia #OU3AB mortality
age )G0
o ?ence" !ysiologic 0dry ice1 and two stage am!utation
At two years E0O
M2
'BL#V5 F0O
'ulmonary )0O
Renal insufficiency
se!sis
stro:e
de!ression H seen in E*O
o AocalC
Barly
o .leedingLematoma
o !ain H !antom vs stum!
+0O ave it !ost o!
2*O !ain severe
Bventually settles
o stum! non,ealing )*O
o stum! infection H E0O
o revision to AIA H )*O
AateC
o contralateral am!utation )*O
o a.ove :nee am!utation )*O
o MSI !ro.lemsC
6le/ion contracture
.one s!urs and osteo!orosis
aderent scar
stum! edemaLcongestion
e/cessive residual soft tissue
callous and cyst
o neuromas
o failure to rea.ilitate
only F0O wal: at 2 years
ruteford is more o!timistic
*0O ave SOMB a.ility to am.ulate at )
year
197.Co!pare arterial/ *enous and neuropat"ic ulcers@
o Arterial H dorsum footLdistal" no .leeding wit mani!ulation" irregular edgeL!oor
granulation" no surrounding inflammation" atro!ic cangesLno !ulse" !ain worse
at nigtL.etter wit de!endencyLworse wit elevation&
age )G)
o Venous H gaiter area" venous oo;e on mani!ulation" sallow round edgeLgood
granulation" surrounding inflammation" li!odermatofi.rosisL!igment" mild !ain"
relieved .y elevation
o Neuro!atic H under callusesL!ressure !ointL)<* M'$" .ris: .leeding wit
mani!ulation" !unced out" dee! sinus" surrounding inflammation" as neuro!aty"
normal circulation" no !ain&
SoC
Consider location" res!onse to mani!ulation" .lood su!!ly" !ain res!onse to !osition"
stigmata of associated disease
198.Pat"op"ysiologic !ec"anis!s in dia.etic foot:
o Arterial iscemia in ti.Lfi. vessels
5ere is NO microcirculation !ro.lems contrary to initial animal
e/!erimentations
'rofunda and crural vessesl are affected
o Neuro!atyC
loss of nociL!ro!rioce!tion leading to trauma
Aum.ical muscle denervation
6oot arcitecture messed u!C
o cavus < claw toe
o fle/ture contracture
Aoss of neuroinflammatory res!onseC
res!onse to infection is .lunted
Normally" 'ainLinfection causes release of neuro!e!tides
0su.stance '1 tat release istamine" increase !ermea.ility and
attract cells to site of in4ury&
Neuro!e!tides ARB released .ut tere is no umeral res!onseM
o Sym!atetic dysregulationC
AV sunting 0less !erfusion to te tissue" more to te s:in
no sweat ,Q dry s:in
o Klycosylation of .asement mem.rane and tissue !roteins ,Q
Aimited 4oint mo.ility
B/travasated al.umin cause tissue edema
difficult to eal incisions
noteC tere is NO effect on o/ygen or nutrient diffusion
All leads to !ro!ensity to re!eat trauma" loss of !rotective refle/es and weigt .earing
redistri.ution& #ecreased arterial circulation com!licates matters furter&
2f no !al!a.le !ulses H need angio& 2f diminised !ulses H i&e& less tan tri!asic H non,invasive
study first to see if #SA is re>uired&
age )G2
#irect >uote from RuterfordC
UThe 5"esen%e o' neu"o5a(h$ gene"a++$ "eBui"es a "e&as%u+a"iza(ion unde" %ondi(ion o'
5e"'usion (ha( ,ou+d no( "eBui"e "e&as%u+a"iza(ion in (he absen%e o' neu"o5a(h$8 U
Non,invasive tests of arterial inflow" including 5C O2 sat" can .e !oorly !redictive of ealing
under tese circumstances&
)s(eom$e+i(is &s Fha"%o( 'oo( -
Carcot footC !rogressive degenerative osteo!orosis of foot .ones secondary to
neuro!aty& Aeads to deformities" foot swelling and erytema&
Carcot foot !resents wit swelling and erytema&
2F .ed rest witout anti.iotics sould settle Carcot foot" .ut not osteomyelitis&
E&a+ua(ing 5( ,(h Dibe(i% u+%e"'oo(-
#rainage s/s
Usual 'V# >uestions
Se!sis review
R6 and R6 5/
On B/amC
'ulses H d! and !t gotta .e tri!asic
2# ulcersLsinus" dd arterialLvenousLneuro!atic
'ro.eLde.ride necrosis
Aoo: for e/!osed .one
#o !lain /,ray loo:ing for gasM
)&e"a++ 5"in%i5+es in ("ea(ing diabe(i% 'oo(-
#e.rideLdrain o.vious infection
Control systemic se!sisLy!erglycemia
age )GE
Assess for Asc occlusive disease" as well as neuro!aty
#efine status of 6OO5 arteries
Restore ma/imum !erfusion !ossi.le
Aoo: for" drain" de.ride residual infectionLnecrosis
Manage o!en wounds wit dressing
CAROTIDS
199.,ranc"es of xternal Carotid artery:
o Anterior
Su!erior tyroid
Aingual
5ransverse 6acial
6acial
o 'osterior
Occi!ital
auricular
o Ascending
Ascending !aryngeal
o 5erminal
Su!erfical tem!oral
2nternal ma/illary
200.Internal carotid artery anato!y:
o Cervical segment Hno .rances
o 'etrous segment H small !terygo!ataline to internal ma/illary
o Cavernous segment H a:a carotid si!on
Kives off o!talmic artery
o Cere.ral segment
MCA
ACA
Circle of -illis is !resent in com!lete form in only 20O of !ts&
201. xternal carotid to internal carotid a@ collaterals:
o 2ntracranial,e/tracranial
're,willisian anastomosis
Or.ital,o!talmic
age )GF
Meningo,y!o!ysial
Occi!ito 0BCA1 to atlantic .ranc of verte. ral
#ee! Lascending cervical 0BCA1 to lower verte.ral
BCA to BCA across midline
Rete mira.ile
o #ural arteries to .rain surface
o Small inter,territorial communications
Ae!tomeningeal collaterals
3etween terminal cortical .rances for main cere.ral arteries
across te .order of vascular territories
202.Clinical presentations of cere.ral syndro!es:
52A , R2F duration
Crescendo 52A H same s/s .ut increased fre>uency" o: .etween e!isodes&
Stro:e in evolution H stars as 52A .ut e/tent of deficit and fre>uency is increasing wit overall
worsening neuro status
Ka;e toward side of lesionM
age )G*
o 2CA H monocular i!silateral visual sym!toms !lus MCA
o MCA H
CA emi!aresis < emianestesia
A5hasia 2 %an*( 'ind ,o"ds
o L sided (e""i(o"$
D$s5hagia 2 %an*( 5"onoun%e ,o"ds, s+u""s
o R ;9DED TERR9T)RT
CA neglect
A!ra/ia 0can9t carry out !ur!oseful movement1
o 'CA H
omonymous visual field loss
denial of .lindness , Anton9s syndrome
o ave to ave .ilateral verte.ral occi!ital lo.e !enomenon
o can9t see wit unilateral stro:eM
visual allucinatinos
loss of reading 0ale/ia1
confusional state
amnesia
discoordination
b+ind, ha++u%ina(e, a+e7i%, amnes(i%
o ACA H
CA sensory canges
ina.ility to wal: 0gait a!!ra/ia1
a!aty" mutism
%an*( ,a+=, no( s5on(aneous, u"ina"$ in%on(inen(
o V3
crossed findings 0i!si CN !alsy and CA e/tremity sensoryLmotor
deficit1 H in .rain stem
vertigo" disorientaton" dise>uili.rium
s!eec !ro.lems
iccu!s
hi%%u5s and diseBui+ib"ium
Tab+e 1QA/38 ;igns and ;$m5(oms o' 9FA/Re+a(ed 9s%hemi% E&en(s
GA;FHLAR
TERR9T)RT ;TM.T)M; ;9IJ;
2CA 5ransient monocular visual canges
lasting a.out E,* minutes and
!resenting as
Amaurosis fuga/
Rarely ?orner]s syndrome
3lindness
age )GG
3lurry or foggy vision
3lind s!ots" colors" sa!es
5unnel vision
2n only )0,)*O" curtain,li:e
.lindness ascending or descending
trougout visual field

Rarely eadaces
MCA #ifficulties in com!reension or
language !roduction" difficulties
!erforming motor tas:s or calculations"
incoordination" num.nessLtingling on
one side of .ody" wea:ness in arm and
leg
A!asia" head and e$e
de&ia(ion (o,a"d +esion,
a5"a7ia, neg+e%(,
anosognosia, contralateral
sensory deficit" contralateral
!aresis" confusional states
ACA Num.nessLtingling on one side of
.ody" wea:ness of leg more tan arm"
difficulties wal:ing
Contralateral sensory deficit"
contralateral !aresis" a5a(h$,
mu(ism, "edu%ed
s5on(anei($, gai( a5"a7ia,
u"ina"$ in%on(inen%e
203.-isual syndro!es:
o 3asicsC
occi!ital corte/" ten to mid.rain" ten to ciasma" ten o!tic nerves&
're,ciasmal fi.ers H outside travels to i!silateral tem!oral retina"
fi.ers su!!lying nasal retina are on te inside and cross over&
o O!tic nerve severed H com!lete .lindness
o Ciasm in4uryC
longitudinal cut H cut inside cross over fi.ers tat su!!ly nasal
retina H
o .ilateral eteronymous emiano!sia H .i tem!oral
.lindness
transverse !artial cut into fi.ers tat travel on te outside tat
su!!ly tem!oral retina H
o Contralateral nasal .lindness
o 'reciasm fi.ers H contralateral omonymous emiano!sia H
R .rain is watcing A side H A nasal" and R tem!oral fields are affected
204.Indication for carotid duplex:
o See #o!!ler notes in 2
nd
sectionM
o 2ndicationsC
3ruit in asym!tomatic !t
Seen in *O of !ts a.ove *0 yoa
age )G+
'resent in only 20O of !ts wit ?# significant stenosis
Amaurosis fuga/
6ocal 52A
6ollow u! of :nown Q20O stenosis in asym!tomatic
#ro! attac:s 0rare1
CBA setting
o CVA in candidate for CBA for OR !lanning
o 2ntrao!erative assessment of CBA
o CBA witout arteriogra!y
o 6ollow u! after CBA 0single study at )2L)2 after surgery1
o Can trust US ifC
No !ro/imal CCA irregularities
No :in:sLloo!s
No aneurysms
Kood >uality study
2ndications for carotid angioC
o Can9t trust du!le/ 0:in:" aneurysm" !ro/imal CCA irregularity1
o 2n e>uivocal du!le/ findings
o #u!le/ can9t sow e/tent of disease
o Sus!icion of tandem or arc lesion
o Uncommon carotid !atology
o 5rauma
o -Lu for stent
205.ICA and CCA Doppler profile
C6A H tree com!onents H
o forward flow" reverse flow" forward flow&
age )G8
2CA !rofile H .i!asic .ecause of elevation of .aseline H
o i&e& no reverse flow
NO5 .ecause of disa!!earance of te Erd com!onent of forward systolic
flow
?a!!ens .ecause of low resistance in 2CA&
2
nd
H reversed H com!onent is gone
Note H s!ectrum window is clear under te curve H no .roadeningM
o -asington criteria H .ased on BCS5" NO5 NASCB5 angiogra!ic correlation
BCS5 H outlines y!otetical normal carotid .ul. and measures stenosis
wrt tis
NASCB5 H com!are distal 2CA to stenosis
May get negative stenosis figures
Com!ared to BCS5" !redicts less severe stenosis
o Angiogram H underestimates stenosis
o MRA !ro.a.ly e>uivalent to du!le/ US
o ?ig sensitivity study
A.le to recogni;e an a.normality
needed for sym!tomatic !ts
o ?ig s!ecificity study
age )G%
a.ile to recogni;e normal artery
needed for asym!tomatic !ts
206.Carotid duplex artery stenosis criteria: %as"ington Criteria
o Si;e of carotidC
At .ul. 0&%F cm M" 0&%2 6
2CA 0&** cm M" 0&F% 6
o Remem.er tat it OVBRBS52MA5BS te stenosis 0BCS5" not NASCB5 criteria1
o Remem.er" tat it gives ranges tat do NO5 a!!ly for NASCB5 0+0O stenosis 1 &
o May .e a!!lica.le to ACAS 03= ANK2O G0O stenosis1
o NormalC no !la>ue" smoot walls" .oundary layer se!aration in .ul.
o R )* O mild S3
o )G,F%O mar:ed S3" no systolic window
o *0,+%O 'SV Q)2*" '#V R)F0 cmLsec" mar:ed S3" 2CALCCA Q )&8
o 80,%%O 'SV Q)2*" '#V Q )F0 cmLsec" !oststenotic tur.ulence" 2CALCCA Q E&+
o OcclusionC no flow
May .e wrong in EO of cases H ence AA-A=S confirm tis wit angio
or MR2&
207.Consensus panel on 0S criteria on carotid stenosis:
o 5ese are more !ractical ten -asington H .ased on Nascet tecni>ue and range
of measurements of stenosisC
o R*0O
'SVR)2*
B#VRF0
Ratio R2
o *0,G%
'SV )2*,2E0
Visuali;ed !la>ue
B#V F0,)00
age )+0
Ratio 2,F
o Q+0
'SV Q 2E0
Visi.le !la>ue
B#V Q )00
Ratio QF
208.Ot"er useful *elocities !easure!ent for carotids
o QG0O stenosis H e/ternal Oregon validation wit angio
'SV Q2G0" B#V Q+0" ratio Q E&2&
Accuracy %0O
o NASCB5 Q +0O stenosis
'SV Q280" B#V Q 80" Ratio QF
''V %*O
o Q80O stenosis
'SV Q2*0" ratio QF
%0O accuracy for +0,%%O range
o 2ntrao! du!le/ assessment of CBA
Re!air if 'SVQ200
o Su.clavian artery stenosis
Retrograde 0notced1 verte.ral flow
o No graded 'SVs values vs occlusion for verte.ral artery flows
o Verte.ral stealC
See eiter reversal of flow or stalled flow
're,steal , 3ac: 0systoly1 and fort 0diastoly1
age )+)
#on9t confuse wit !asic flow in verte.ral vein
209.1re2uency of Sur*eillance of known asy!pto!atic stenosis
o Asym!tomatic Q G0 stenosisO
2f 'SVR)+* cmLsec
'rogression is FO over 2) monts
2mage annually
2f 'SV Q )+*O
'rogression 2GO over )F monts
?ence image > G mont
210.#ec"anis!s of stroke:
RuterfordC
2scemic 080O1 H non !ainful
emorragic 020O1 H !ainful
o dd of 2C?
trauma
tumor H !rimary vs met
?5N
Amyloid angio!aty
AVM
aneurysm
2scemicC
20,E0O are due to ma4or B/racranial and intracranial cere.ral vessels
E0O are due to em.olism 0close to *0O in !ts younger F0 yoa1
o Unli:e carotid origin" tese are NO5 territorial
F0O of stro:e H no :nown cause
Sro:es a!!en .ecause ofC
Bm.olism
5rom.osis
o B/tracranial
o 2ntracranial
lacunar
?y!o!erfusion
age )+2
o 6low related !enomenon are due to decreased cardiac out!ut and occlusion
'atology leading to stro:eC
Aterosclerosis %0O
o Artery,artery ateroem.olism 0MC1
o trom.osis
Bm.olism
o Cardiac 0A6" !ost M2" valve1
o Q *0O in !ts R*0 yoa
OterC
o 6M#
o Iin:s < loo!s
o 5raumatic occlusion
2ntimal dissection
o 2nflammatory angio!aty
ta:ayasu" KCA
o Aneurysm
o 2ntracranial vessel diseaseC
Vasculalitis
'AN
-eird and wonderfulC
moyamoya" fi.rinoid necrosis" amyloidosis"
arteritis
o C5#
o allergic" granulomaout" infectious
o '& )88E

Summary of Non,ASC causesC 6M#L:in:sLdissectionsLarteritisLlacunar
211.$a. and in*estigations for &IA:
NB- definitionC a ("ansien( e5isode o' neu"o+ogi%a+ d$s'un%(ion %aused b$ 'o%a+ b"ain,
s5ina+/%o"d, o" "e(ina+ is%hemia, ,i(hou( a%u(e in'a"%(ion& NO5B H no more 2F time line is
given
##C
'artial com!le/ sei;ure
Com!licated migraine
#emylienating !rocess
Meta.olic 0glucose" liver" lyte a.normality1
'syciatric , conversion disorder
Sro:e in youngC F0O are cry!togenic
em.olism
age )+E
#issection
6M#
Moyamoya
C5C
55'
y!ercoag
'reliminary 3-C
c.c 0!lt" R3C1"
Cr
gluc" ?gA)C"
li!id !rofile"
BSR
fi.rinogen" omocystein"
'5L'55L2NR
drug screen"
reum 0R6" ANA" A'A" lu!us1"
y!ercoag , if young
o 6VA" !n 202)0" A5 def" fi.rinogen" omo" ACALAAC" !n C<S" 'A2,)" li!id
!rofile and li!o!rotein a&
rLo mimic:ersC cec: lytes" gluc" A65s" cardiac screenLolter"
26 BCK is a.normal" order BC?O&

2deally di''usion ,eigh(ed MR9 of te ead" if not availa.le C5 ead
o According to te latest recommendations of te A?ALASA 200%

Wh$ FTV (o "o
SOA
emorrage"
old stro:es"
lacunar stro:es"
cec: laterality 0and li:eliood of em.olic disease1&
owever" #- MR2 is .est for 52As&&&
#o!!lerLimaging H witin 2F .y guidelines" accredited la.
2f !t ad stro:eC
t'A H indicated witin E ours of stro:e" not later& Sei;ures is contraindication to t'A&
Maintain slig y!ertension" no y!otension
Anti!latelets and statins" no e!arin&
Urgent studies 0as for 52A1
age )+F

AsideC
Auditory evo:ed !otentials H only good for diagnosis of demyelinating disease 0e&g&
MS1" not for anatomic locali;ation&
Only E0,*0O of CVAs are !receded .y 52A
Mortality of initial stro:e E0O
o Second stro:e E*O
o Su.se>uent stro:es G*O
G monts !ost stro:e H
o *0O ave residual deficit"
o 2*O non,am.ulatory"
o u! to 20O a!asic"
o 2*O re>uire care"
o E0O de!ressed
Stro:e in evolutionC
o Mortality 20,80O
o Com!lete Recovery wit medical tera!y FO
o Recovery wit surgery H u! to +0O
Asym!tomatic stenosisC
o Seen in E0O Q*0yoa
o 80O of stenosis !rogress .ut !rognosis is generally .enign
2f Q80O wit ris: factors u! to E*O ris: of 52ALstro:eLocclusion at G
mots" FGO at )2 monts
3ruits
o Seen in *O of Q*0yoa
o Only 20O of .ruits are associated wit Q*0O stenosis
o Only alf of ?# significant stenosis ave .ruit
o Stronger !redictor of CA#
age )+*

212.Recurrent C-A after &IA or C-A:
o Stro:e after 52A
?igest in te first 2 wee:s
Overall GO !er year
)0O ) year" )GO at 2 years" 2GO at E years"
ten declinesM
Stratifiation of 52A ris:C
if ris: factors !resentC
o AUQG0 yoa"
o 3U3' Q)F0L%0&
o ClinicalUemis!eric vs monocular"
o #Uduration Q ) our"
o #U#M
ris: of recurrence may .e as ig as 8O in 2 days according to A3C#
2
criteria
5otal scores ranged from 0 0lowest ris:1 to + 0igest ris:1&
Stro:e ris: at 2 days" + days" and %0 daysC
Scores 0,EC low ris:

Scores F,*C moderate ris:
Scores G,+C ig ris:
age )+G
o Recurrent CVA after CVAC
%O !er year" steadyM !& )880
)
st
year CVA
recurrence
Annual
recurrence
Recurrence
declinesD
'ost CBA
annual
recurrenceD
CVA )0O %O No 2O
52A )0O GO =es R)O
asym!tomatic , 2,*O , 0&EO
Moores dataC 2f ulcer is Q F0 mm
2
and cavernous H ten annual stro:e may .e as ig as +&*O"
even wen no significant stenosis is !resentM Controversial&
213.&i!ing of CA wit" respect to C-A
After 52A H calculate A3C#2 rates and may offer surgery same admission
After CVA H if neurologically recovered" witin 2 to F wee:s& 200% ?arvard review course
recommends witin 2 wee:s .ut tere are no RC5 to su!!ort tisM
Old adageC 7if even a!!ened witing a day" fi/ in a dayN if witin wee:" fi/ in a wee:N if witin
mont H fi/ in a mont8 H may ave some valueM
214.Contraindications to CA
o Carotid aneurysm
o Ma4or !revious stro:e wit significant neurologic dysfunction
o Acute ma4or stro:e
'remature .lood flow increase may e/acer.ate deficitC
o Area lost its9 autoregulatory a.ilities
o 3lood .rain .arrier is disru!ted
Bdema
2ntracranial .leed
age )++
?ence" may ave to wait u! G wee:s ten rLa neuro status&
2f com!lete recovery is seen earlier" Ruterford suggests may o!erate .efore GL*2
215.Co!plications of CA:
M<M a.out GO for sym!tomatic and EO for asym!tomaticC
2MMB#2A5BC
neuro , !erio! stro:eLy!er!erfusion"
o see y!er!erfusion on E,+ day
local , .leedLinfectionLCranial n 0y!oglossal" marginal1 H most reversi.le "
systemic , ?# insta.ilityLM2&
#2S5AN5 H
restenosis , )0O at 2 y" )+O at )0 y , int y!er!lasia vs ASC&&& !atc reduces incidence&
'atc aneurysm
216.Conduct of CA:
Koals H remove !la>ue" re!air artery" avoid com!lications
ConsentC indications" ris: and .enefit discussion
3eac cair !osition" nec: e/tended" ead turned
Regional anestetic" monitor CA arm activity and fre>uent neuro cec:s
Bar,lo.e H to ni!!le !re!
Cut along ant .order of SCM
o S:in
o 'latysma
o Reflect SCM laterally
Ko in front of 4ugular vein" 2# facial vein
o Iey to .ifurcation
Bnter seat" !reserve ansa and vagus
#issect 7!atient away from artery8
Aoo! CCA" BCA" su! tyroid" 2CA
o 'reserve y!oglossal
2n4ect .ifurcation wit lidocain" don9t dissect tere
As: neuro to maintain 3'" neuro cec:" e!arin" circulation time
5est clam! 2CA wit .a:er clam!" neuro cec:
Clam! CCA" BCA" cli! su! tyroid
CCA,.ul.,!ro/ 2CA longitudinal arteriotomy
'enfield or #allar tool !lus Aower
5ransect !la>ue in CCA" wor: it u! around BCA orifice" transect at te .ase of te 2CA
Bversion BCA endarterectomy
Continue BA !lane to 2CA" feater out or tac: wit +C0
age )+8
Clean surface
'atc
Unclam! 2CA H ten reclam!
Unclam! BCA and CCA
6inally unclam! 2CA" neuro cec:
'rotamine" emostasis" consider drain
o Aess ematoma
Close !latysma
Sta!les
o Remove tese 'O# ) and re!lace wit stereostri!s&
217.Indication for CA endarterecto!y:
o Occluded i!silateral 2CA wit ongoing sym!toms refererra.le to te side were
BCA stenosis is found
Am!utate 2CA" flus close after BCA endarterectomy
218.Difficult access to ICA: "ig" ICA/ difficult ICA
o Standard access H u!!er tird of C2
Cut sternocleidomastoid .ranc of occi!ital artery
will allow to lift y!oglossal u!
B/tend incision to mastoid
o #ivide !osterior digastrics m H middle tird of C)
Mo.ili;e and elevate lower !ole of !arotid gland
5ransect SCM at mastoid !rocess
o Su.la/ate 5M$ 0call for ead and nec: surgeon to el!1
#on9t dislocate
Need nasotraceal intu.ation
o Resect styloid !rocess H u!!er alf of C) in *0O of cases
o Cut of !osterior !ortion of te mandi.le ramus H gets you a.ove C) in )00O of
cases
Aateral mandi.ulectomy
!reserve inf& Alveolar nerve
o 6inally" going retro4ugular on initial a!!roac e/!osing te carotid can get you
sur!risingly igM 0#r& ?a44arLAewis1
219.(er*es encountered during CA +
2n4ury rate H overall )0O&&& Most are transient&
o ?y!oglossal FO , tongue deviation" swallowing
age )+%
MC in NascetLruterford
o Vagus EO , oarse voice" airway !ro.lems
Osler course ma:e it most common in4ury
Very often overloo:ed" ence ma:ing it li:ely te MC CN in4ury
o Marginal mandi.ular 2O , droo!ing corner of mout" drooling
o Kreater auricular H num. ear
o Su!erior laryngeal H sustain ig !itc
o S!inal accessory H soulder dro!
o Sym!atetic cain H orner9s
220.(ascet findings:
2 year results
Asa vs ASALCBA
o i&e& NO statins& Medical management is outdated&
Ratio of stenosis diameter to normal !ro/imal 2CA
2GO vs %O for +0,%%O"
o NN5 G for R +* yoa
o NN5 E for !ts Q +* yoa
o ma4orLfatal stro:e )EO vs EO ARR )0O
22O vs )GO for *0,G%O" NN5 )+
o No difference in ma4orLfatal stro:e
Need com!lication rate R *O
AsideC
BC5 , Q +0O stenosis
?ig E0 days surgical stro:e of +&*O
E year GO vs ))O fatalLdisa.ling stro:e in favor of surgery
Dina+ %on%+usion-
)& CBA is offered in all sym!tomatic !ts wit severe stenosis 0Q +0O1
a& 'ts Q +* yoa ave most .enefit
2& 2n ig,moderate stenosis 0*0,+0O1C
a& for male H if good o!erative ris: for OR
.& for women H only for !ts wit !ersisting sym!toms unres!onsive to medical
tera!y" emis!eric 52A AN# ris: 'V# factors
c& 5ere is no reduction in fatalLdisa.ling stro:es in Nascet study
AsideC if see clam! defect on com!letion angio H leave it alone" don9t fi/ it unless it is
?# significant" it will eal& 0Osler1
D"8 H8W8M8 <a"ne((- The a55"o5"ia(e use o' %a"o(id enda"(e"e%(om$8 WAMF, 3003
age )80
;$m5(oma(i% > L0K s(enosis8
All !ts are .etter off wit surgery" .utM
Most .enefit seen inC
?ealty elderly !ts Q +* yoa
?emis!eric 52A 0NO5 monocular1
'ts wit tandem e/tracranial and intracranial lesions
'ts witout angiogra!ic evidence of collateral !atways
'erio!erative ris: is iger in te following !ts" 3U5 surgery is still .eneficialC
-ides!read leu:oaraiosis
o Significant ris: factor for stro:e
o 'oorly defined y!odense wite matter lesions
Unli:e sar!ly defined infracts
o Overall .enefit is smaller
Occlusion of CA carotid artery
2ntraluminal trom.us
;$m5(oma(i% R L0K s(enosis-
6or most .enefit smaller& 5e following !ts may .e ?ARMB#" !articularly if tey ave few
Ris: factors C
'ts wit monocular 52A
-omen
5e !resence of te following R6 increase .enefitC
o Q+* yoa
o Male
o 2C
CaveatsC
CBA carries 2O incidence of #isa.ling stro:e& SoC
'recise measurement of stenosis is essential
6ollow e/clusion criteriaC
o 2m!ending organ failiure
o Serious cardiac dysfunction
o Aate stage cancer
5ese !ts not li:ely to .enefitM
221.Asy!pto!atic Carotid artery stenosis and ACAS findings:
o E% centers" elite surgeons
o Kood ris: !ts" mostly men
o * year results
o Most events occur after E years
Stat significance only after *
t
year
age )8)
o Stenosis Q G0 O
3ut NO de!endence .etween e/tent of stenosis vs .enefit
))O vs *O" ARR GO" NN5 )+
men )2&)O vs F&)O , ARR 8O
,omen 88LK &s L8QK ARR 18MK no( s(a( signi'i%an(
o 6atal stro:e and disa.ling stro:e H no stat difference
o Need com!lication rate R EO
o 6emales or Q 80 yoa li:ely no .enefit
o Recommended for good ris: male !ts wit E year life e/!ectancy" at least G0O
stenosis& Results for women less certain&
AF;T 'indings-
h((5-s("o=e8ahaPou"na+s8o"g%gi%on(en('u++s("o=eahaXQM10343M
Aarger study
community surgeons" no elite re>uirements
te only study to sow stat sig difference in fatalLdisa.ling stro:e of 2&*O&&
females ave 52N= stat significant .enefit" uncertain clinical .enefit
;o ,ou+d 9 o''e" su"ge"$ on as$m5(oma(i% sideV
ris: of stro:e for asymtomatic R 80O is generally low
o ),2OLyear"
F2* !t" sta.le *0,+%O stenosis
* year cumulative ris: of event is *&FO
o Recommendation to consider OR a.ove 80O stenosis only
NN5 is 8E according to 3arnett !a!er 0) O yearly" i su!!ose1
)+ according to NB$M review 0for *O ARR over * years&&&1&
Ris: of an event wit stenosis a.ove 80O , may .e as ig as ))O !er year&&&&&
te greater te stenosis" te more R6 tere is" te greater te incidence of stro:e&&
o some re!ort incidence of stro:e in Q80O as ig as E*O at GL)2
also" only E0,*0O of !ts wit CVA ave an antedecent 52A
o so can9t rely on waiting for reversi.le sym!toms of 52A as a warning system for
incoming stro:eM
;(i++, (he mos( %ommon e&en( in AFT;AFA; 2 M9, J)T s("o=e88
AFA; a%Bui"ed s(a(is(i%a+ signi'i%an%e 'o" s("o=es on+$ a'(e" a sma++ bu"s( o' s("o=es
a'(e" M
(h
$ea" o' 'o++o, u5
o i8e8 no signi'i%an%e ,ou+d ha&e been "ea%hed i' on+$ 'o++o,ed 'o" 4 $ea"s
o on+$ 1Q/13 o' is%hemi% s("o=es ,e"e "e'e"ab+e (o i5si+a(e"a+ %a"o(id s(enosis8
Unfortunately" te very same factors tat ma:e stro:e more li:ely witout an o!eration" also
increase !erio!erative ris: of stro:eM

age )82
2n ACAS" te following factors increased 5e"io5e"a(i&e "is= o' s("o=e, T9A, o" dea(h
o Anatomical factorsC
Contralateral carotid stenosis QG0O
Contralateral si!on stenosis
o Clinical factorsC
'rev CVA
?y!ertension
#M
6emale gender
Age Q+* yoa
C?6
o 'rocedural factorsC
Com.ined carotid,cardiac surgery
i&e8 FL disease, .GD 'a%(o"s, 'ema+e, age >LM
At te same time" te following factors increase ris: of aving a stro:e in asym!tomatic
stenosis if followed non,o!erativelyC
o Anatomical factorsC
Soft" ecolucent
!la>ues
CA 2CA occlusion
Silent i!silateral
infarction on C5
o Clinical factorsC
?tn
#m
Smo:ing
?y!erli!idimia
?y!eromocystein
98e8 .GD "is= 'a%(o"s:
so te decision to do surgery in asym!tomatics is not an easy oneM
o on te one and" multi!le R6 ma:e !ts more !rone to stro:e 0from .aseline
2O to as ig as ))O1
o on te oter" te very same R6 ma:e !t more !rone to !erio!erative
CVALdeat&
Also" te .enefits of CBA do not get reali;ed until E
rd
year !ost o! and it does not
a!!ear to .e cost effective in 80 year olds" or females
Medical tera!y is getting .etter& $u!iter trial sowed *0O reduction in stro:es and
M2s wit statin tera!y at 2 years in asym!tomatic !ts&
Fon%+usion-
o 2f !t as
less tan E year life e/!ectancy"
CA occlusionLstenosis"
age )8E
as 6B- vascular R6"
is a female
under 80O stenosis"
M medical tera!y is .eneficial& 'articularly statins 0$u!iter trial1&
o -o is an ideal asym!tomatic candidate for CBAD
male
R +* yoa"
Q80O stenosis
R6 for 'V#
No contralateral occlusion

o 2f decision to o!erate is made" it is im!erative for te o!erator to ave less
tan EO com.ined M<M stro:e ris: to ensure gradual reali;ation of GO 0at
most1 of a.solute ris: reduction over te ne/t several years&&&
o So for te e/am intent" unless you can !rove to te e/aminer your record
of asym!tomatic CBA is low and you understand te ris: variation wit
different R6 trown in te mi/" 29d .e careful suggesting CBA for an
asym!tomatic !tM&
Carotid Stent , still investigational& Crest Hfor sym!tomatic !ts is not out yetM
Reserved for ig ris: Sym!tomatic !ts 0tecnically or !ysiologically1& 6or
asym!tomatic H use stent in off la.le investigational setting only
222.Carotid patc"ing + ad*antages and disad*antages:
o #isadvantagesC
Aonger clam! time
'otential .low out if use vein
'otential infection if use !rostetic
o Advantages
Aower restenosis rate
Reduced acute carotid trom.osis
Reduced !erio! neurologic rate
o All tese were suggested .y Cocrane 200G
metaanalysis" F0 !erio!erative stro:es are !revented
!er )000 !tsM No RC5 done&
age )8F
Com!lications of CBAC
2mmediateC
o Neuro
deat
?y!er!erfusion
stro:e
Bm.olismLtrom.osis
#isa.ling 2O
2f !t is Sym!tomatic ris: is u! to GO" if asym!tomatic EO
o AocalC
CN in4ury
age )8*
3leeding
-ound deiscence
infection
o SystemicC
?# insta.ility
M2
Aong,termC
o Recurrent stro:e A65BR re!air
Annual ris:
0&EO if asym!tomatic
2O if sym!totic !ost CVA
R)O if sym!tomatic !ost 52A
o Recurrent stenosis
o 'atc .low outLaneurysm
223.Recurrent stenosis after CA:
#efined as recurrent stenosis Q+0O&
o 2? in first 2 years" ten aterosclerosis
o MetaanalysisC
)0O at 2 years" )+O at )* years&
?igest in first year" ten low rate
Kenerally )O !er year
o Only one tird to one alf are sym!tomatic
o 2ncidence Significantly reduced .y !atcingC
down to 2O at 2 years !&2)0E
acas H +0,80O reduction wit !atcing
o 2f sym!tomatic" consider longevity AN# nature of lesionC
At * years H +FO" at )0 years F2O
Most lesions are 2?" not atero
Aow ris: for ateroem.olism
o Management o!tions includeC
Aggressive medical tera!y
o #i!iridomole and ASA is .etter tan 'lavi/ and ASA
o Statins 0$u!iter trial1
CBAP!atc
ResectionPautologous inter!osition grafting
CAS
age )8G
o 2f asym!tomatic" o!tions includeC
#u!!le/ follow,u! H )LE of lesions will regress wit remodeling
OR H very rarely as natural / is .enign and re!eat OR is mor.id affair
224. Carotid s"unt co!plications?
Sunt ty!es H outlying 0'ruitt,2noara1 vs inline 0$avid1
Need *0 mlL)00 mgLmin of .rain tissue !erfusion during clam!ing
#issection
Bm.oli;ation
Migration
'oor distal end!oint managment
3loc:age .y de.ris
May forgo sunt if Q*0 mm?g .ac: !ressure&
2f !t ad !revious CVA use sunt routinely 0unless doing it awa:e1 H !& )%8)&
$avid" Argyle" 'ruitt,2nnoara&
225.CA and CA,7 + decision !aking in *asc surgery: p@ CD
CA3K .y itself causes cere.ral ateroem.olism
Ris: of stro:e for CA3K alone is G&+O in ?ert;er RC5
o Seems ig" .ut tat9s wat 7#ecision ma:ing in Vascular Surgery8 state
Sorting out wat is res!onsi.le for te event !ost com.ined re!air is difficult
6irst" define ig vs low neuro ris:
o ?ig H tese need to .e addressed eiter .efore or during CA3K
.ilateral severe 0Q80O1 asym!tomatic stenosis
severe sym!tomatic
unilateral severe asym!tomatic wit CA occlusion
o Aow ris: H unilateral severe asy!tomaticC tis can wait and followed on
du!le/
Secondly" define ?ig vs low Cardiac ris:
o Unsta.le angina ?2K? ris:
o Sta.le angina AO- ris:
Com.inations to .e consideredC
age )8+
'ts wic is ?ig neuro and ?ig Cardiac ris:C
o Controversial" now tat CAS and 'C2 are availa.le
o 5raditionally Com.ined o!enC
Acce!t ig ris: of M<M com.ined )*, )+O
o OrMAocal CBA ten F8 CA3K
5at9s wat 29d suggest on my e/am
o OrM 'C2 and CBALCAS com.inedLstaged
o No good data to su!!ort one or te oter
'ts wit ?ig neuro and Aow cardiacC
o CBA first" ten CA3K in F,G wee:s
o Recent review 0aug 2008 .y Claggett1
CAS was worse tan CBA for sym!tomatic"
CAS .etter tan CBA for asym!tomatic com.inations wit CA3K
Aow neuro and ?ig cardiacC
o Cardiac first" ten monitor carotid
o Com.ined ris: of com!lications sould .e less tan 8O
2f can assure tis" may do com.ined" oterwise stage
Aow neuro and Aow cardiac ris:C
o May do eiter" de!ending on te institution results H com.ined vs staged
226.CAS trials:
2nitial early deat and mortality were )0O" .ut current series 0)+"000 !ts1 H *O&
Recurrent stenosisC )0O at 2F mont& 'redis!osing factorsC
6emale
CR' elevation witin F8
Redidual !ost !rocedural stenosis
2ncom!lete a!!ostion
Age Q +*
?ig ris: !tsC !& 20)0
.h$sio+ogi% %"i(e"ia-
o Severe CA# re>uiring 'C2 or CA3K
o ?/ of C?6
o Severe CO'# re>uiring ome O2 and 6BV
)
R20O !redicted
o Severe renal failure 0 Cr Q E or 2F01
Ana(omi% %"i(e"ia-
age )88
o 'rior CBA wit restenosis
o CA vocal cord !aralysis
o Surgically inaccessi.le lesion H atLa.ove C2" inferior to clavicle
o Radiation induced stenosis
o 'rior i!silateral radical nec: dissection
SA''?2RB trial of CAS in ?2K? R2SI !atients
randomi;ed to CAS 0n U )G+1 or CBA 0n U )G+ 1
com.ined end!oint of stro:e" deat" and M2&
y!otesis tat CAS was not inferior to CBA
Most of te randomi;ed !atients were asym!tomatic H +0O in eac grou!
At E0 day H more M2 in surgery grou! F&F vs 8 O" te rest e>ual&
E0 day te ris: of stro:e
CAS E&)O" CBA E&EO NO #266BRBNCB
E0 day Mortality
CAS , 0&GO vs CBA 2&0O P U 0&EG NO #266BRBNCB
E0 day M2
CBA , G&GO vs CAS grou! 0F&FO1" P R 0&0*1&
o most of te M2s were non,S"
o identified on routine !ost!rocedure la.oratory
studies"
E0 day com.ined end!oint deatLstro:eLM2 sameC
CAS , F&FO vs CBA, %&%O P U 0&08
) year dataC
o Ma4or i!silateral sto:e H CAS 0O vs CBA E&*O& P U 0&02
o M2 , CAS 2&*O vs CBA 8&)O& P U 0&0E
1 $ea" %ombined end5oin( a( 1 $ea" 'a&o"ed (he FA; g"ou5
o 1380K &s8 3081K P = 080M
Fon%+usion 2 FA; is non/in'e"io":8
5e ARC?eR
study of a stent and !rotection devicea
registry of ig,ris: !atients
te com!osite end!oint 0stro:eLdeatLM21 was +&+O"
o included a *&EO stro:e ris:N
o te ris: of stro:e or deat was G&GO at E0 days&
o 'atients aving CAS for restenosis following CBA ad an e/tremely low
ris: of stro:e 00&+O1N
o tose !atients wit end,stage renal disease ad an e/traordinarily ig ris:
028O1&
o
age )8%
5e BVA,ES study
o Bndarterectomy versus Angio!lasty in 'atients wit Severe Sym!tomatic
Carotid Stenosis
o Randomi;ed"
o NO5 ?2K? R2SI sym!tomatic !atients ,i(h >A0K %a"o(id stenosis to
CAS or CBA
o Re>uirementsC
vascular surgeon
min 2* CBAs 0wit no u!!er limit of M2LCVA1
interventional !ysician
)2 CAS !rocedures OR
E* interventions in te su!ra,aortic trun:s"
at least * of wic were on carotid artery
at least two !rocedures wit a new device
o !rimary end !ointC com!osite of stro:e and deat at E0 days&
o 2G) !atients underwent CAS and 2*% ad CBA and were analy;ed for
!rimary outcome measures&
o trial was designed to sow noninferiority
o stenting was found to carry a greater ris: tan endarterectomy&
o 5e E0,day
incidence of any stro:e or deatC
E&%O after CBA and %&GO after CAS
disa.ling stro:e or deatC
)&*O after CBA and E&FO after CAS
i8e8 ARR 3K
o No stat difference in Systemic com!lications or local com!lications
o Cranial nerve in4ury was more common after CBA 0+&+O1&
o no difference in results from ig vs low enrolling centers
o no difference .tw e/!erienced vs less e/!erienced o!erators
5e trial was sto!!ed !rematurely after enrollment of *2+ !atients .ecause of
7.ot safety and futility"8 as CAS carried significantly iger ris: tan CBA&
CriticismC
o 20 !ts in stent grou! were done witout cere.ral !rotection
o * different stents" + different em.olic !rotection devices used
o Aow e/!erience of interventionalist was re>uired
SummaryC
age )%0
So BVAE H
o no ig ris:"
o CBA FO vs CAS %&GO
fatalLdisa.ling ,)&* vs E&* in favor of surgery
Sa!!ire H
o ig ris:
o CBA 20O vs CAS )2O in favor of CAS
S'ACB trial
o Stent,!rotected angio!lasty versus carotid endarterectomy in sym!tomatic !atients
o )200 sym!tomatic !atients
o 52A or moderate stro:e witin )80 days
o randomi;ed to CAS or CBA
o Bm.olic !rotection used only in 2+O of !ts
o 5e !rimary end!oints
o i!silateral iscemic stro:e or deat witin E0 days of te !rocedure
o deat or stro:e was G&8FO in te CAS grou! and G&EFO in te CBA grou!&
o 5e autors concluded tat te study failed to !rove te non,inferiority of CAS
com!ared wit CBA 0!,value of 0&0%1
o 2m!ortant age related outcomes of stentingC
o No difference in stro:e rate in less tan +* yo
o ))O vs +O in stro:e in Q +* year olds 0in favor of CBA1
Crest trialC
6inal results are still !ending
Aead in !ase resulsC
o morality and stro:e in CAS
E&FO for asym!tomatic and *&GO for sym!tomatic
o Outcome eavily de!endent on ageC
Age 0N1 Stro:eLdeat O
RG0 0)201 2 0)&+O1
G0,G% 022%1 E0)&EO1
+0,+% 0E0)1 )G0*&EO1
Q80 0%%1 )2 0)2&)O1
'ending studies H
2nternational Carotid Stending study 02CSS1 H only sym!tomatic !ts
Asym!tomatic Carotid Surgery 5rial `2 0AC521
Asym!tomatic Carotic 5rial 0AC5)1
MetaanalysisC
age )%)
Aue.:e9s H 200+ H E0 day stro:e or deat )&E%O
3amanandam9s H 2008 H E0 day ris: of stro:e )&E8O
5ese results" wen com!ared to CBA are marginally iger&
228.$ ICA occlusion@ %"at do do?
See if sym!tomatic& 2f yesC
Confirm flow distri.ution wit Jenon C5L'B5
2f definite y!o!erfusion" may .e one of te rare cases of e/tracranial to
intracranial .y!ass
o Anoter indication for BCL2C .y!ass, moyamoya and ig carotid
aneurysm tat can9t .e ligated and reconstructed at nec:
Recogni;ed tat s/s are emodynamic" NO5 em.olic
o Oterwise" all tat need to do" ligate origin of 2CA and o!en u! BCA
COSS study !ending in 200%" #ecem.er
'revious study of BC2C3 study in )%8G H .y!ass U medical tera!yM
229. -erte.ral insufficiency:
## of synco!yC
Stro:e
V32
Cardiogenic soc:
?y!otensive state
B!ile!tic sei;ure
Meta.lic state
Rull out
o AocalC
Aa.yrintine
Su.clavian steal
o SystemicC
Ortostatic dro!
Meds
B/trinsic com!ression
Anemia
C?6
Arrytmia
Malfunctioning !acema:er
Venomotor !aralysis of dia.etics
3rain tumor
Usually see immediate s/s wit ra!id ead sa:ing or turning if coclearvesti.ular
!ro.lems are te source of sym!toms& 2f !ro.lems wit com!ression of verte.ral artery
and low flow H see delay of several seconds" !osition de!endent&
age )%2
StudiesC MR2 0.rainstem infarct1" angio 0!ositional and cranio,caudal loading1"
?olter
V32C includes s/s and stro:es
S/sC
Synco!y
#i!lo!ia
Vertigo
Ata/ia
E0O microem.oli;ation H !redominant cause of stro:es
o 6rom innominate" su.clavian" verte.ral
G0O Aow flow H !redominant cause of s/s .ut not stro:es
o 'la>ue
o Osteo!yte
Concomitant verte.ral and carotid a& re!airC
?as to .e on te same side
VA is dominant" stenosed Q +*O OR res!onsi.le for em.oli
't understands tat ris: of com!lications e/ceeds aggreagated M<M for individual
re!air of carotid and verte.ral lesion 0Ruterford com!anion1&
V) H most common stenosis at orifice due to aterosclerosis
V2 H most common !atology H com!ression
VE H MC !atology H trauma" 6M#" dissection& Stays o!en due to collaterals from
occi!ital a&
VF,surgically incaccessi.le
230.Re*asculari>ation of *erte.ral artery:
Su.clavian .y!ass 0rare1
Carotid trans!osition H most common" for V) lesssions
Carotid .y!ass H for V2 lesions" at te .ase of te s:ull&
o Off common
o Off e/ternal
o Off occi!ital
o Off cervical 2CA
231.Descri.e steal/ outline treat!ent:
6or steal" one needs to aveC
o #ominant verte.ral a& affected 0M0K Le'(" 2*O .ot or R1
o 'ro/imal su.clavian 0or innominate on te R1 stenosis
Reduced inflow
age )%E
o #ecreased !eri!eral resistance in u!!er e/tremity 0due to e/ercise1 causes
reversal of flow in verte.ral artery& 2f artery is dominant" significant
verte.ro,.asilar insufficiency is seen
5o diagnose stealC
o #u!le/
o will ave same direction in CCA and su.clavian 0red1 " .ut reversed in
verte.ral 0.lue1&
5o treat suclvian steal is to treat !ro/imal su.clavian stenosisC
Bndo
'5A" dodgy as may occludeLdissect verte.ralLA2MALR2MA
origin
O!enC
5ranstoracic
o 5rom.o,endareterectomy
o Ascending Aorto innominateLsu.lavian .y!ass
B/tratoracicC
o Carotid su.clavian trans!osition
o Carotid su.clavian .y!ass
o A/illo,a/illary 3' 0rare" des!ised .y !urists1
o 6emor,Qa/illary 3' 0very des!erate and rare1
232.,ranc"es of su.cla*ian artery:
o Verte.ral
o 5yrocervical trun:
o Costocervical trun:
o 2nternal mammary
o #escending or #orsal sca!ular 0*0O of time1
233.,ranc"es of axillary artery:
o )
st
!art
su!reme toracic
o 2
nd
!art
toracoacromial
lateral toracic
o E
rd
!art
su.sca!ular
!osterior umeral circumfle/
anterior umeral circumfle/
age )%F
234.1eatures of spontaneous carotid dissection:
CauseC 6M#" marfan" Blers,#anlos" muco!olysacaridosis
o 3lunt traumaC im!ortant" .ut clearly tis is not S'ON5ANBOUS category
Most diagnosed !ost factum after neuro deficit set in
=ounger !ts
Clinically seeC
o ?eadace PL, nec: !ain
o oculosym!atetic syndrome
o Neuro deficitC
Stro:eL52ALSA?
'alsies of lower CN 0V22" 2J" J" J221
o Com.inations for te a.ove tree
Unilateral eadace PL,
2!silateral oculosym!atetic syndrome
delayed focal neuro deficit
Angiogra!icallyC
A!!ears as 7string sign8
luminal smoot stenosis
ta!ered occlusion" distal .ranc occlusion
low flow in MCA
a.ru!t reconstitution of lumen
!seudoaneurysm of e/tracranial arterial segment
5reatmentC
USUAAA= medical H
Anticoagulation
o e!,Qwarf E monts
o reimage at E monts
if resolved" ASA
if not H E monts of anticoag" re!eat dril
surgical H not common
trom.ectomy"
!rogressive intraluminal dilation"
endarterectomy"
intimectomy"
graft inter!osition vs ligate vs BCL2C .y!ass
'rognosisC
2f no sym!toms or mild H %0O recovery to good function&
2f sym!toms H F0O&&&
See treatment of .lunt carotid in4ury in 5rauma
age )%*
235.Carotid 1#D:
Most common distal 2CA
o #o!!ler may miss it
*O ris: of stro:e over * years H i&e& don9t treat asym!tomatics
?ave )0,*0O incidence of intracranial aneurysm H always cec: for tese and fi/
!ro!ylactically
?ave 8,F0O incidicence of renal a& involvement
236.xtracranial Carotic artery aneury!s:
## H dilated tortuous su.clavian and !ro/imal CCA
o Btiology
Aterosclosis +0O
5rauma H !enetrating and .lunt
#issection
6M#
'ost CBA wit vein !atc angio!lasty
2nfection H used to .e most common cause" from tonislitis
Media !ro.lemC
Marfan syndrome
Cystic medial necrosis
2dio!atic medial arterio!aty
o Mc location H CCA at .ifurcation" 2
nd
mc H su.clavian&
o S/s and signs
'ulsatile mass in nec: or tonsilar fossa
Com!ressionC
Auricular !ain
#ys!agia
?orner9s syndrome H com!ression of stellate ganglion
52A or stro:es
?emorrageC RARB
##C
Iin:ed Lcoiled artery
o Carotic :in:s H F times more common in females
o Coils H more common in :ids
Carotid .ody tumor
Non,vascular nec: tumor
2nvestigationsC
o #u!le/" angio" C5
o 2f distal 2CA involved H .alloon occlusion test H
age )%G
E0 min occlusion and assessment of neurologic status as !re!aration
for ligation
3ac: !ressure Q*0 mm ?gH safe to ligateM
5/C
Resect and restore arterial continuity for CCA and !ro/imal 2CA lesions
#istal 2CA
o Bndo 0stent" em.oli;ation1
o O!en
ligation H only if .ac: !ressure is Q *0 mm ?g and o: occlusion
test
Iee! !t anticoagualted for )0L+ to minimi;e trom.us
!ro!agation
3y!ass H consider e/tra,intracrainial .y!ass if failed .alloon
occlusion test&
Note" tat emodynamic results of B2C3 are inferior to carotid
re!air
237.Carotid .ody tu!or:
o Arises from afferent ganglion of Klosso!aryngeal n&
o 'araganglioma" cemoductoma
o Cemorece!tor res!onsive to y!o/ia" y!ercar!nia" acidosis
if stimulated" will increase RR" tidal volume" ?R" 3'"
vasoconstriction" catecolamine release
o Bm.ryologyC
Neural crest ectoderm and mesoderm tat migrated along te
afferent nerves
o Autosomal dominant ineritance" .ut most s!oradic
o *O guidelineC
Metastatic
3iocemically active H !eoM
3ilateral 0E0O of tese are familial1
o May .e !art of MBN ) and 2
o #ifferentiate from y!er!lasia in ig altitude dwellers
o On e/am H
!ulsatile" not e/!ansile"
can move it sideways .ut not u! and down 06ontain sign1
o Sensitive to rads .ut te only definitive control is surgery
Sam.lin classificationC
age )%+
#is!laced
Com!ressed
Bncased
Clear off 2CA" ten resect wit BCA& See Oral e/am file&
238. Inner*ation of carotid .ody:
o afferent in!ut to te reticular formation in te medulla via glosso!arengyal
n&
o Connects C3 to .rain stem so tat it can res!ond to y!o/ia 0!rimarily1" and
0lesser degree1 y!ercar.iaLacidosis
o Stimulation !roduces increased RR" 3'" vasoconstriction
MESENTERIC ISCHEMIA:
239.%"at are t"e non)at"erosclerotic causes of c"ronic
!esenteric isc"e!ia?
o Aortic dissection
o 6M#
o Radiation in4ury
o 3uerger9s
o #rugs H Cocaine" ergot
o Bm.olism
6rom A6
6rom aneurysm
o vasculitis
5a:ayasu
Neurofi.romatosis
age )%8
5ese form middle aortic syndrome
Reumatoid artritis
SAB
'AN
240.Causes of intestinal isc"e!ia:
Bm.olus 0most common1
o Sudden
o Inown A6LM2Lsource of em.olism
o No !receding K2 /
o #iarrea and a.do !ain
5rom.osis
o Kradual
o 'receding / of cronic !ro.lems
o #iarrea 0mala.sor.tion" /ylo;e test1
o Kasless a.domen on J,ray
o Collaterals on angio" orificial o.struction
Non,occlusive
o #ue to cardical failure" se!tic soc:" dialysis" digitalis li:e drugs
;("ing o' sausages on angio AJD 5"uning o' a"(e"ia+ b"an%hes
De%"eased &enous '+o,
'a!averin 2A is el!ful
Venous 5rom.osis
Acute 2MA occlusion
o MC due to ru!tured AAA
Aoss of collaterals in 2MA and 22A distri.ution
241.Doppler findings in !esenteric isc"e!ia:
o SMA H Q2+* 'SV" QF* B#V& 6or Q+0O stenosis
o Celiac , Q 200 'SV" Q** B#V& 6or +0O stenosis
Normal flow in Celiac is )00cmLsec
Normal flow in 2MA %E,)8+
o NoteC
Normal flow in celiac is .i!asic H low resitance system
2t does not cange wit fastingLfed state
SMA will cange !asicity wit fasting
6asting H tri!asic
'ost !randial H .i 0dro! in !eri!eral resistance1
Also" re!laced R?A may ma:e flow .i!asic
?ence" all measurements in SMA are done in 6AS52NK
state
age )%%
242.Co!!on *ariations of Co!!on Hepatic Artery:
Normal anatomy seen in 80O
)0O A?A is off A gastric artery
))O R?A and FO C?A can ta:e off SMA
243.&reat!ent of !esenteric isc"e!ia:
o 2ndicationsC
Classic /
'ost !randial !ain
6ood fear
-eigt loss
2 out of E vessels occludedLstenosed
Mimic:ers ruled out
'ancreatitis
Cancer
'U#
!syciatric
o Celiac and SMA orificial stenosis t/C
'taLstent H !oor !atency rates" !oor dura.ility" less sym!tomatic
im!rovement
3y!assC
Su!raceliacC
o Su!raceliac aorta less diseased
More diff to e/!ose ten iliac
May need to enter cestM
o Su!raceliac to C?ALSMA
o 3ifurcated #acron
Vs Seatle slug
8 mm single #acron to Aongitudinal
o!ening of .ase of celiac onto aorta
Aong !atc angio!lasty of te celiac
origin wit te ood of te graft to te
SMA&
?ood starts on aorta and ends on te
Celiac&
o Retro!ancreatic tunneling to SMA
2liacLinfrarenal aortaC
o 3ifurcated
o Basier to e/!ose
o Ris: of :in:ing
o 2nflow may .e more diseased
age 200
5ransaortic endarterectomyC
o Most difficult
o 2f ave simulataneous renal a& revasculari;ation
Medial visceral rotation
Control su!raceliac aorta
244.Differences .etween acute and c"ronic !esenteric isc"e!ia:
o Acute
!revious em.olism elsewere
no !revious K2 sym!toms
clear source of em.olism
!atent SMA origin" meniscus" no collaterals
s!aring !ro/imal 4e4unum
o cronic
vasculo!at
!revious !ost!randial anginaLweigt loss
low flow or intra !la>ue emorrage
no em.olism
clot at SMA origin" see collaterals
entire SMA distri.ution :noc:ed out
245.How to deter!ine intraoperati*e .owel *ia.ility?
o ClinicalC
visi.le !al!a.le !ulsations in te mesenteric arcade
normal colourLa!!earance
!eristalsis
.leeding from cut of surface
o Aa.oratoryC
#o!!ler signal on antimesenteric side
-oods lam! and fluorescin in4ection
Surface o/ymetry
2ntracolonic !? monitoring and 2MA stum! !ressure
for large .owel
RENOVASCULAR DISEASE
246.Differentiate Reno*ascular Hypertension fro! ot"er causes
of H&(?
o More common in Caucasians
o =ounger age
age 20)
o 5in !ts
o Aess fam /
o Recent onset
o Accelerated course
o More severe 0#iastolic Q )0*1
Oter im!ortant cluesC
o Onset of a;otemia on ACB2
o ?y!o:alemia wile off diuretics
o ?y!ertension resistant to E drug
o Unilateral small :idney
o A.do .ruit
247.#ec"anis! of renal H&(:
o UnilateralC
One cli! model
Renin driven
On stenotic sideC
o one sided renin secretion ,Q aldosterone"
te oter 0Normal1 side
o com!ensates .y natriuresis
o :ee!s te volume down
y!ovolvemia and y!o!erfusion drives u! renin
Unilateral stenosis leads to over!roduction of renin wic H troug Angiotensin 22" drives
!ressure u!" remodels CVS" retains Na" and may ave direct to/ic effect on tu.ular
elements of :idney& 5is effect is counteracted .y contralateral normal :idney wit
natreuresis&
o 3ilateralC
two cli! model
volume e/!ansion"
initially" driven .y .Ll secretion of renin,Q aldosteron
Bventually aldosterone is su!!ressed
New set !oint for e/!anded effective circulating volume is
esta.lised
CVS undergoes com!ensatory y!ertro!y
3ilateral RAS leads to y!eraldosteronism" y!ervolemia" and ten sustained ada!taion of
te CVS to iger !ressures& Renin will .e su!!ressed .ut ?5N !ersists due to
y!ervolemia and ada!tive CVS canges !ersist
age 202
2t is difficult to distinguis early iscemic ne!ro!aty 0reversi.le1 from cronic
!arencimal disease 0not reversi.le1& 2n te end" y!ervolemia" vascular y!ertro!y and
vascular reactivity sets in&
248.Captopril nep"rogra!:
Can9t use for .ilateral RAS and if Cr is elevated 0a.ove )&2 or )001
Angiotensin 22 H
o constricts efferent arterioles" maintaining K6R wen .lood flow is
reduced to glomerulus&
o -it cronic RAS" K6R .ecome tigtly de!endent on increased
!arencimal !aracrine A522&
o 2ncrease in ACB2 acitivity dro!s AK22 !roduction
K6R dro!s as well&
Nuclear !erfusion scan done at .aseline" ten ) after 2*,*0mg ca!toril&
-ill see decreased e/cretion of trace wit RAS side com!ared to normal
contralateral renal a&
#iagnosis is made if
'ea: u!ta:e is delayed Q )) min
!ea: of K6R is delayed
age 20E
asymmetry of u!ta:e .etween :idneys
cortical retention of radionuclide
249.Renal a@ duplex:
o Accessory a& seen in )0O
o A.errant 20O 0enter :idney outside of ilum1
2deally" would li:e to interrogate entire renal artery wit G0 degree angle
corrected #o!!ler&
o 'SV Q )80" RALAortic 'SV ratio Q E&* , Q G0O stenosis
o B#V Q )*0 UQ 80O stenosis
'arencimal angle,inde!endent s!ot readings& Allow to measure R2" wave
sa!e" A5
Resistive inde/
o 'ea: systolic fre>uency sift H '#6SL'S6S
Q *O difference .tw :idneys indicative of Q *0O stenosis
R2 Q 80O , igly unli:ely to .enefit from surgery or revasculari;ation
o Seen in intrarenal vessel disease
o Seen in su.ca!sular collection
o Seen in low CO
5arda and !arva waveforms
acceleration time Q 0&0+ sec
acceleration time inde/ QE mLsec
2
250.Surgical causes of "ypertension:
o RAS
o Aortic coarctation
o 'eocromocytoma
o Conn9s
o Cusing9s
251.Causes of R- H&(/ R- "ypertension:
o RAS
o Aterosclerosis
o Congenital H .andsLwe.s
o 6M#
o Bm.olism" leading to !arencimal diseaseC
o ?eart
o Aortic aterosclerosis
o Aortic aneurysm
o Renal artery
age 20F
o Renal aneurysm
o #issection
o Aortic
o renal
o AVM
o 5rauma
o -eird < -onderful
VasculitisC
5a:ayasu
'AN
Neurofi.romatosis
Necroti;ing Angiitis
'ost surgeryC
'ost .y!ass stenosis
'ost trans!lant stenosis
252.R- H&( treat!ent and results:
2n treating RV ?5N your o!tions includeC
o Medical tera!y
o 2nterventionalC

2ndications for interventionC
RV ?5N
2scemic ne!ro!aty
Acute traumatic occlusion of renal artery 0see trauma1
Concomitant su!re,renal aortic clam!ing re>uiring
reconstruction of renal a&
3efore considering revascular;ation" loo: at Renal !erfusion scanM
Measure corte/ widt 0cortical atro!y H Q !oor res!onse to revasc1
Renal !erfusion scan 0#MSA .etter tan #5'A1
9( +oo=s a( (ime (o (he .ea= a%(i&i($ 2 measu"es 5e"'usion o' (he =idne$
o Kood study to order to wor: u! failing graft due to anastomotic failure
E7%"e(ion 2 measu"es %o"(i%a+ 'un%(ion
o Cortical atro!y H .ad !rognostic sign"
as is !ole,!ole :idney si;e R 8 cm
;u"gi%a+ "e%ons("u%(ion-
Aortorenal .y!ass
5rom.oendarterectomy
age 20*
o 5ransrenal
o 5ransaortic
S!lancnorenal .y!assC ave to ensure celiac artery !atency
o ?e!atorenal H easier" :oceri;e duo" 2# !ortral triad"
sort .y!ass to R renal
o S!lenorenal H 32K deal" need to rotate viscera"
discect .eind !ancreas
B/,vivo reconstruction
Endo- .TAs(en(
2deal for 6M# 0medial fi.ro!lasia ty!e1
'rimarily for ?5N treatment"
not effective for CR6 long term
Je5h"e%(om$ H only if :idney is non,functional AN# disease is non,reconstructa.le
-yD
o B>uivalent .lood !ressure res!onse wit
revasculari;ation and ne!rectomy
o 2m!roved renal function after revasculari;ation
confers a survival advantage&
)''e" su"ge"$ (o 5(s ,i(h se&e"e HTJ (ha( is di''i%u+( (o %on("o+ medi%a++$ on
mu+(id"ug "egimen8
Role of '5ALstent in management of Renal Artery StenosisC

5ere is no indication to intervene as 3' is o!timally controlled
'5A is not dura.le for renal failure&
'5A as no effect on survival&
Restenosis could .e u! to E+O
o less wit stenting&
o AS5RAA study is designed to com!aire '5A vs medical tera!y&
'reliminary results , B>uivalentD
'5A wor:s .est for non,osteal lesions due to to 6M#&
May .e offered for !ts wo are at ig ris: of o!en surgery&
Results of renal '5A vs surgeryC cumulative data from Ruterford
?5N ?5N ?5N CR6 CR6 CR6
Cure Sta.ili;ed 6ailed 3etter No cange -orse
Surgery" !&)8)E,)F )2O +EO )*O F0O *0O )0O
BN#O" !& )8F0 )0O *0O F0O 20O G0O 20O
Same cure for ?5N .tw surgery and BN#O .ut E time more failure wit endoM
age 20G
2nitial 20O vs F0O im!rovement in CR6 .ut tat does not last for BN#O
o At * years only 2*O sustain teir renal function
+*O get worse OR go on dialysis
Com!are tat to **O dialyais free stay for * year for o!en surgery
O!en surgery for Renal failureC
o 5e worse te failure te .etter te res!onse to revasculari;ation
Creatinine level g 2m!rovement in R6C
R )&8 g E0O
QE&0 g G0O
6or !rognostic info to see if tere is going to .e an im!rovement in
R6 !ost surgery" te most im!ortant is te RA5B of renal function
decline .efore surgery
o #ia.etics may not res!ond to revasculari;ation
253.Indications of conco!itant aortic and renal reconstruction:

58 181L, 180L
Asym!tomatic !ts C
NO role for prophylati reonstr!tion.
Assuming tat due to !rogression of aterosclerosis RV ?5N occurs first followed .y
renal failure
2f we were to ta:e )00 asym!tomatic !ts
o e/!ect RV ?5N to develo! in FF&
-it medical managementC
o out of FF" )G 0EGO1 will !rogress to loss of te renal function&
2f tese )G !ts are o!erated u!on" )) 0G+O1 will regain R6"
o te rest 0* !ts1 won9t&
;o MK o' 5(s ,i++ be +os( i' no su"ge"$ is o''e"ed8
)00,Q FF,Q)G,Q*M&
2f Surgery was offered at te outset on all )00 !tC
ten e/!ect to ave
o OR mortatlity of *&*O"
o early tecnical failure of 0&*O
o late failure in FO H
i8e8 a (o(a+ o' 10 5( 6K# ,i++ be ha"med i' su"ge"$ is done 5"o5h$+a%(i%a++$8
Ris: .enefit analysis does not su!!ort !ro!ylactic re!air in asym!tomatic !ts
Sym!tomatic !atientsC
Unilateral diseaseC
o 2f ?5N H if mild" do ca!to!ril" if !ositive H OR
o 2f ?5N severe H em!iric OR
age 20+
3ilateral diseaseC
o 2f RAS Q80O , em!iric OR
o 26 RAS G0,80O , cec: ?5N
severe H OR
2f mild H cec: CR6 H
2f a;otemic , em!iric OR"
if not H medical tera!y
Em5i"i% "e5ai"-
o for !ts wit ?y!ertension or ?y!ertension AN# CR6
o a causal relationsi! .etween RAS and tese se>uella as not .een esta.lised
e7am5+e-
G0 yom needs o!en AAA re!air" tigt .ilateral Q 80O stenosis" Cr 200& -ould you offer
surgeryD
-ould li:e to :now if e is y!ertensive&
2f e is" ten offer surgery
o Additionally" 'ts as a;otemia wic strengtens indication for
intervention
2f !t as unilateral RAS and ig CR .ut NO ?5N" ten tere is no role for
reconstruction&
254.Renal artery aneurys! repair indications: RA aneu
%0O e/tra" )0O intrarenal
BtiologyC
o Aterosclerotic
o Most common H medial degenerative !rocess
o 6M#
o #issection
o Vasculitis 0'AN" 3ecet1
o trauma
o Sym!tomatic
Ru!ture 0calcification not !rotective1
!ain
Bm.oli;ation leading to ?5N" CR6
?ematuria
Collecting duct o.struction
acute dissection treatening :idney via.ility
o any si;e in women of Cild .earing age < !regnant
age 208
OSABR suggests watcful waiting for last trimester" re!air in te
first&
o Q E,F cm in asym!tomatic
Management o!tionsC
Re!air wit inter!osition graft
B/,vivo re!air wit autogenous vein reconstruction
'ro/Ldistal ligation wit aortorenalLe!atorenalLs!lenorenal .y!ass
Ne!rectomy along wit aneurysm
5ranscateter em.oli;ation of saccular aneurysm or stent
255.Approac" to renal arteries:
o Midline or 5ansverse incision
Advantage of transverse incision H
andle instruments !er!endicular to longitudinal a/is of te
.ody
o Su!raum.elical
o Mid a/il,Qmid clavicular
o R renalC
R medial rotation of colon and Ioceri;ation of duoL!anc ead
#issect middle of R renal a& first
2f start distally , trou.lesome .leeding
Retract R renal vein ce!alad
o May need to ligate adrenalLsmall .rances
5en dissect osteum
o Aigate lum.ar veins
o 'us 2VC laterally
o A renalC
A medial rotationC .etter tan transmesenteric
Aigate A gonadal and adrenal vein
Retract A renal vein ce!alad
o Aorta is dissected for * cm infrarenally
o 6luid load and give )2&* g of manitol .efore clam!ing
o KSV graft H
s!atulate .ranced !ortion and anastamose it to aorta first
5unnel R graft retrocaval" A graft .eind R renal vein
256.x)*i*o reconstruction: indications
o -en reconstruction Q F* min
o All lesions involving .rances 0RAA" stenosis"
AVM" dissection1
age 20%
o 6ailure of !rior reconstruction
257.Indication for repair of renal artery in trau!a:
Sta.le !t
2n te setting of la!arotomy for oter reasons
5ime to in4ury more tan G 0if one :idney is damaged1
5ime to in4ury more tan 20 0if SOAB or 3O5? :idneys are damaged1
-y conservative a!!roacD
Success of revasc is only E0O
2f successful H )2,*0O cance of y!ertension"
if decided to treat concervatively H ave F0O cance of ?5N
AAA
258.AAA epide!iology and cause:
#efinitionsC
Aneurysm if more tan )&* normal diameter
Arteriomegaly , Q )&* diameter in long multi!le segments of arterial
system wit no discerna.le aneurysm&
o 2,G times more common in males
o 2,EL)000 !ersonLyears
o A.ove G* yoa H *O males" )O females"
2n !ts wit 6? of first degree relativeC
o 2*O males" *O females 0i&e& * fold1
o 2n men" AAA .egins at *0 !ea:s at 80
+O of tese is familial
o 2n women" .egins at G0
)2O of tese is familial
o 2f !t as AAA" tere isM
2*O cance of aving iliac aneu
o Common iliac aneurysm
)0 times more common tan internal iliac
B/!ect growt rate of F mmLyear
No ru!tures seen less tan E&8 cm
R twice more common tan A
Re!air if a.ove E cmD
BVAR !referred
$VS 2008" F+C)20E,))
)2O cance of aving toracic aneu
REO of AAA will ave fem Aneu
age 2)0
2f see H need to fi/ if
o sym!tomatic 0massLAteroem.olism1
o if Q2&* cm if asym!tomatic
Conversely" *0O of fem aneu will ave AAA
o according to Ruterford 0osler course say %0O1
E0O of fem aneu will ave !o! aneu
E,+O AAA will ave !o! Aneu
o E0O of !o! aneu will ave AAA 0*0O according to osler1
'& )*E*
CauseC
'roteolytic en;ymes 0MM',2" %" tissue ini.itors of MM' , 52M'1
#ecreased elastin in infrarenal aorta
#ecreased vasa,vasorum in infrarenal aorta
Reflected !ulse waves from aortic .ifurcation
2nflammationLinfection
Kenetics
259.Principal !atrix fi.ers in aorta/ w"at c"anges are seen in
AAA?
o Blastin and collagen
o MM' H matri/ metallo!roteases res!onsi.le for degradation
o #egradation of elastin is res!onsi.le for growt
o Aoss of collagen is res!onsi.le for ru!ture
260.Risk factors for AAA D&C&IO(:
2NCRBASB# R2SI inM
o Smo:ing
o 6?
o Older age
o Male gender
o ?ig col
o CA#
o CO'#
o 5all statue
#BCRBASB# R2SI inM
o N a.dominal imaging witin * years
o #V5
o #M
o 3lac: race
age 2))
o 6emale gender
261.(atural "istory AAA
o Rate of e/!ansion for aneurysm .etween F,G cm is )0O !er year
o Ru!ture ris: is related to si;e
o RF cm 0
o F,*cm 0&*,*O
o *,G cm E,)*O
o G,+cm )0,20O
o +,8 cm 20,F0O
o Q8 cm E0,*0O
Selection of !atients for surgeryC
Ris: of ru!ture
Ris: of surgery
Overall !t fitness
Aife e/!ectancy
Mos( 5(s do no( bene'i( '"om "e5ai" un(i+ M8M %m, un+ess i( is ,oman 6M %m#
R* cm H follow wit serial US at G monts intervals
*,*&* cm H elective re!air in young" low ris: " good life e/!ectancy suc tat
eventual re!air is almost certain if *&* cm tresold is reaced
6or iger ris: !ts" consider raising o!timal tresold si;e" e&g& G cm&
o See modified Aee criteria
Screening reduces mortality of AAA .y *0O&
*0O of aneurysm .etween F&0 and *&* cm re>uire fi/ing witin E years 0A#AM"
UI1
+*O of aneurysms .etween *&0 and *&* cm re>uired re!airM
Note mall aneurysmsC
2F"000 conse>uitive auto!sies over 2E years
F+E AAA found
))8 of tese H ru!tured
)EO of tese are under * cm 0difficult to !redict si;e on auto!sy1
Ris: of ru!ture for AAA F&G,*&F is a.out 0&*,)O annually&
262.Rele*ant C& findings in pts wit" AAA
o Venous anomaly
Retroarotic A renal vein
#u!licated 2VC
Aeft sided 2VC
age 2)2
o Renal anomalies
?orsesoe
'elvic :idney
o Nec: of aneurysm
'ro/imity to renal a
Accessory renal a&
o Oter items to considerC
2nflammatoryD
2liac aneurysmD
'resence of Aortoiliac occlusive diseaseD
Oter significant non,vascular !atologyC
K3 cancer" .owel Ca etc
SMALCeliacL2MAL22ALrenal stenosis" arcs of Reolan
263.R1 for AAA rupture
Normal rate of growt H 0&F cmLyear
'ROVBN
o Aarge si;e
o ?5N
o CO'#
o 6emale gender
o smo:ing
SUS'BC5B#
o 6amilial ineritance" !articularly in females
o Bccentric sa!e
o ?ig e/!ansion rate
o A.sentLminimal trom.us
264.Ruptured AAA !anage!ent:
o A.do !ainL.ac: !ain in !t wit :nown AAA
o 6aintingLy!otensionLa.do !ulsation
o 5ender !ulsatile mass
rLo C?6" swollen legs" a.do .ruit" 2VC dye in arterial !ase
o Bsta.lis 2V .ut :ee! 3' at te minimal level to allow normal mentation
o 2f sta.le" may consider C5 for !lanning BN ROU5B to OR
o 2n OR H !re! first" induce wen ready to cut
o Su!raceliac clam! if large ematoma at nec:
o No e!arin if large ematoma
o 5ry to get away wit sortest !rocedure 0i&e& tu.e graft1
o 3ac: .leed iliacs !rior to com!letion
age 2)E
o Consider need to leave a.do i!en
Wha( de(e"mines 5oo" ou(%ome in "u5(u"eV
)& Admission and intrao! S3' R%0
2& 'reo! Cr Q 200 mmol 0Q2&*1
E& 'reo! ?g R)00
F& OR .lood loss Q+ A
*& More ten )0 u !R3C transfusion
G& OR uLo R 200cc total
+& 5em! R%)6 0EE C1
265.Infla!!atory AAA:
o Same rate of ru!ture as AAA
o Unclear if tis is distinct entity vs !art of te s!ectrum
o No role for !rimary management of oter organ involvement
i&e& #O not decom!ressLrelease o.structed ureters
may stent tem
most will settle conservatively after AAA re!air
o Role of BVAR is .eing defined
o Use 5eflon !edgets if re!air o!en H do retro!eritoneal
266.Indications for retroperitoneal RP repair:
o ?ostile a.domen
o 2nflammatory AAA
o ?orsesoe :idney
o Ascitis
o 'eritoneal dialysis
o o.esity
267.Anato!ic criteria for -AR:
o Nec: Q)* mm long" RE0 mm wide" R G0 degrees angulated
o Nec: is non,divergent" no calcium" no trom.us
o 3ifurcation minimum
2F mm Coo:" 28 mm 5alent if .ifurcated
Non,issue for AU2
o R %0 degrees aortoiliac angle
o 2liacs at least + mm
268.&ypes of endoleaks:
a& !ro/imal" . distal" c troug occluded CA iliac in AU2
age 2)F
sac flow via H
o a& single vessel 0not !ossi.le for long1"
o . more tan 2
structural failure H A H 4unction" 3 H tear or `
!orosity
endotension H sac: e/!ansion wit no endolea:
269.Specific co!plications of -AR )endo*ascular AAA repair
Overall" ris: of Ma4or Adverse Bvents after BVAR is u! to E0O& Most of tese can .e
managed endovascularly& 6reedom from Ru!ture at % years is a.out %FO 0800 cases
from MK?" 3oston1&
BARA=
o Radiation e/!osure to !t and !ersonnel
o contrast allergy
o renal failure
o Access traumaC
!erf"
dissect"
trom.osis
Microem.oli;ation of !la>ue or AAA trom.us
o Kraft dis!lacement or mis!lacement
Occlusion of RA" 22A" SMA
o Bndolea:
o 'ostim!lantation syndrome
fever
.ac:ace
malaise
o graft lim. com!ression H trom.osis" stenosis" occlusion
AA5B
o Kraft migration
o Bndolea:
o Aim. stenosis" :in:" trom.osis
o AAA ru!ture
270.1ollow up after -AR@ ndoleak treat!ent:
C5 scan at ) mont" ten annually
5e !ur!ose of BVAR is to !revent ru!ture of te aneurysm
early identification of endolea:s is intended to el! acieve tis goal&
treatment of endolea:s , te most common reason for readmission of !atients after
BVAR&
age 2)*
20O of !ts e/!erience endolea:
o +O at first C5
Most early endolea:s 0+0O1 disa!!ear
o )EO later
Ris: of ru!ture of ty!e 2ALcom.ined wit 222 is AO-
o in BUROS5AR registry 02800 !ts1 is )O !er yearM
o FO over E years
Still" all ty!e ) sould .e fi/edC
o e/tension vs !alma; vs e/ternal .anding vs conversion to o!en
6reedom from aneurismal ru!ture after BVAR" categori;ed .y endolea:s !resence&
5y!e 22C seen in F0O .efore E0 days" te rest later
No ris: of ru!ture wit ty!e 22
No general agreement a.out te need for graft related interventions in !ts wit
endolea:s
Controversy reC most a!!ro!riate ty!e of intervention for ty!e 22&
o Coil" glue" la!arasco!icLo!en cli!!ing vs o.servation
5y!e 2 wit sac srin:age
o No intervention" continue follow,u!
5y!e 2 wit sac e/!ansion
o Seen in )0O of cases
o Most will recommend intervention
o Sac e/!ansiong migration < distortion of fi/ation sites gty!e 2L222
lea:gincreased ris: of ru!ture
5y!e 2 wit sta.le sac si;e
o Controversial
o Safe to o.serve according to Silver.erg et alM
Sac: enlargement is seen inC
age 2)G
in 20O of !atients wit ty!e 2L222 endolea:
2n )0O of !atients wit ty!e 22 endolea:
2n *O wit no endolea:
271.Drea!/ -AR E and -AR 9 findings
o #RBAM
F00 !t" RC5" te first to sow EO ARR in favor of BVAR
o BVAR ) H
M40 5( in ea%h g"ou5
6it !ts" evar vs o!en
)&+O vs F&+O mortality at E0 days
EO vs +O mortality at F years
Overall mortality same at F years
2GO vs 2%O" NS
#isease s!ecific mortality at F years H EO less for BVAR
Suality of life im!roved for BVAR for E monts only
ConclusionC
Continue to e/!lore te issue
Not enoug evidence to cange !ractice
o BVAR 2
Unfit !ts" evar vs o.servation
%O mortality at E0 days in BVAR grou!
At F years" Overall mortality is G+O vs G*O" sameM
No im!rovement in >uality of life
272. Har*ard #edicare Registry study
Registry review" NO5 RC5
2E"000 !ts wo ad BVAR matced to 2E"000 of !ts wo underwent o!en
20O women" )0O ad M2 !reviously
'erio! mortality )&2O vs F&8O
o ARR 'o" AL/AN 2 3K
o ARR 'o" >8M $oa 2 88MK
Com!licationsC
BVAR o!en
M2 +O %&*O
!neumonia %O )+O
Renal failure *&*O ))O
#ialysis 0&FO 0&*O
Acute mesenteric isc )O 2O
age 2)+
All ave significant !
Mortality .enefit !ersisted for a.out E years
o ) year for G+,+F yoa
o F years for Q8* yoa
F year o.servation BVAR o!en
ru!ture 2O 0&*O
reintervention %O 2O
Aa!arotomyLernia com!lications FO )0O
Mortality com!arison .etween BVAR vs o!en" ?arvard registry
Age
g"ou5
endo&as%u+a" o5en Abso+u(e
di''e"en%e
AAA )&2O F&8O E&GO
G+,G% 0&FO 2&*O 2&)O
+0,+F 0&8O E&EO 2&*O
+*,+% )&EO F&8O E&*O
80,8F )&GO +&2O *&GO
Q8* 2&+O ))&2O 8&*O
-o goes omeD #irect ome vs rea. outcomesC BVAR vs o!enC
age EGAR ).EJ Abso+u(e
di''e"en%e
AAA
AKBS
%F&*O 8)&GO )2&GO
G+,G% %+&8O %2&GO *&2O
+0,+F %G&8O 88&+O 8&)O
+*,+% %F&FO 80&FO )FO
80,8F %0&GO G+&+O 22&%O
age 2)8
Q8* 8F&GO *+&)O 2+&*O
ConclusionC
Aargest o.servational study of o!en vs BVAR
BVAR Survival .enefit de!ends on age
o te older , te more and longer
o Survival .enefit of BVAR disa!!ears wit time
6unctional outcomes of BVAR are .etter
o te older" te .etter H after 80 yoa astounding 2*O ARRX
BVAR reinterventions were .alanced .y la!arotomy com!lications in
o!en grou!
More ru!tures wit BVAR
273. Indications for angio in pt wit" AAA: angio for AAA
o 5ALsu!rarenal aortic aneurysm
o Cronic aortic dissection
o ?orsesoe :idney
o Sus!ected renovascular or visceral arterial disease
o 2lio,fem occlusive disease
o Associated !eri!eral aneurysm
THORACOABDOMINAL ANEURYSM
274.&"oracoa.do!inal aneurys! F&AG
Notes on anatomyC
5in: of a giant slug gradually sliding down ten crawling .ac: u!
?ig ig" ig low" low low" very low" middle
No renal involvement in ty!e ) and *
5y!e 2 is te most e/tensive
5y!e F is a .ad version of su!rarenal aneu 0!ro/ suture line a.ove celiac1
Most are degenerative
o 5inning of media" destruction of SMC < elastin
20O are familial
age 2)%
Syndromes associated 5AAC
o Marfan 0MC1
6amilial H +*O
New onset H new mutation 2*O
o 5urner
o Blers,#anlos
o 'olycystic Iidney
#issection 020O of 5AA are due to A#1
o Conversely" u! to F0O of A# end u! in aneurysm at + years
2nfectionLtrauma 0minority1
o Salmonella" ?&6lu" Sta!" 53" 5re!onema1
'redictors of ru!tureC normal rate of growt H 2 mmLyear
o Si;e Q + cm
o )cmLyear e/!ansion
o ?5N 0diastolic1
o Smo:ing
o CO'#
o Kender 06QQM1
o Age H u! 2&* folds for every decade
6or Q+0 yoa" *0O ris: of ru!ture witin )&* years
Ris: of re!airC
o CO'#
o Rena+ Dai+u"e 2 F" > 300 638M# 2 5oo" 5"ognosis 'o" "e5ai"
o Longe&i($ assessmen(
o Mo"(a+i($ o' "e5ai"-
10K in %en(e" o' e7%e++en%e
30K %oun("$ ,ide
'resentationC
o 'ressure effect
#ys!agia
?orseness
age 220
SO3
Visceral !ressure
Ureteric com!ression
o Ru!ture
2ntra!eritoneal
2nto !leural cavity
2nto R'
2nto K2 0duo1
2nto 2VC
2nto ureter
o Ateroem.olismC
Visceral vessels
Aower e/remity
275.Decision !aking in assessing pt wit" &AA:
Ri:s of OR
o Surgical detail
B/tent
'ro/ < distal
Visceral involvement
Aortic >uality
Calcified
5rom.us in 5%,A2
Comor.idities
Modified Aee" es!ecially Renal failure
Aife e/!ectancy
o Ris: of Ru!tureC
?5N
Smo:ing
CO'#
Si;e
9n gene"a+, do no( o5e"a(e on TTA R A %m 6e7%e5( in ($5e 4 2 M (o M8M as in in'"a"ena+
and Ma"'an 5(s#
Overall" E0 days mortality is close to )0O&&&
5y!e 22 ad 2%O ris: of s!inal cord iscemia .efore institution of ad4uncts
o Aess wit ad4uncts&&
age 22)
276.Strategy for renal protection in &AA:
KoalsC reduce renal o/ygen use" reduce direct renal tu.ular in4ury" maintain
!erfusion
o ?old ne!roto/ins 0ACB2" aminoglycosides1
o #istal aortic !erfusion
o Only !rotective wen renal a& do not re>uire reconstruction
o i&e& for ty!e ) and *M
o Selective visceral !erfusion
o 2t #OBS !rotect te liver
o Retrograde y!otermic renal venous !erfusion to )* degrees
o 3ut :ee! core .ody tem! at E2,EE degrees
o ?olds a lot of !romise according to SafiM
So far" none of tese tecni>ues ave .een sown to definitively reduce incidence of R6
277.%"y is t"e spinal cord at risk during repair of &AA?
S!inal cord .lood su!!ly
o one anterior H !rinci!al
varies in si;e
discontinuous in some !eo!le
receives radicular .rances from intercostals or te u!!er
lum.ar arteries&
age 222
o largest of tese aortic .rances is called te great
radicular artery of Adamc:iewic; or arteria
radicularis magna 0ARM1
arises .etween 5% and 5)2
o two !osterior
arise ce!alad from .rances of te verte.ral a&
run troug te total lengt of te s!ine
end in a conus !le/us of lum.osacral .rances&
5e most li:ely cause of !ara!legia after toracoa.dominal aortic aneurysm surgical
treatment" eiter tem!orary of !ermanently is te interference wit te Adamc:iewic;
artery&
AsideC
anterior s!inal syndrome H .Ll !aralysis and loss of !ainLtem!erature& 2ntact
!ro!rioce!tion
'osteriorC loss of !ro!rioce!tion and vi.ration& 'reservation of touc" !ain and
tem!erature
278.Spinal cord protection !et"ods during &A repair:
'assive 0A/,fem" Kott sunt1
Active
o A atrial,fem .y!ass
o Com!lete cardio!ulmonary .y!ass
o 'erio!erative CS6 drain
S!inal cord !ressureU MA' H CS6"
:ee! CS6 !ressure at R)0 mm ?g
:ee! MA' u!
drain )0,)* ccL
dLc drain on 'O# E
o intercostal aa& Reim!lantation 05%,A21
o e/!editious o!eration
o oter
?g Q)00
C2 Q2
MA' %0,)00
o ?y!otermia
S!inal 0F degrees C1
o 'armacology
Nala/one
age 22E
Steroids
Magnesium
Calcium cannel .loc:ers
O/ygen free radical scavengers
.ar.iturates
asideC
#ifferent tecni>ues were develo!ed since te first 5AAA re!air in )%*FC
)%809s Crawford9s inclusion tecni>ueC
o !reserve !osterior wall of te aneurysm
don9t do tis for Marfan
o reim!lantation of te celiac" su!erior mesenteric" and renal artery islands of
aortic wall into te !rostetic graft&
A renal is sewn in as a .y!ass
o called te Clam!,and,sew tecni>ue&
7te less clam!ing time" te less te incidence of !ara!legia8
goal was to com!lete all te anastomosis in a.out E0
minutes
Se>uential advancing cross,clam!ing also minimi;ed iscemic time
to s!inal cord and a.dominal organs&
5em!orary Aortic 3y!assC
o a/illo,femoral .y!ass
o left atriofemoral .y!ass using a centrifugal !um! witout
e!arin&decom!ression of te !ro/imal aorta
!erfuse cord in a retrograde fasion distally
allows more time to !erform te !rocedure
Reim!lantation of 2ntercostal arteriesC
o 5e vast ma4ority of surgeons re,im!lant intercostals wen !atent
!articularly in te 5%,5)2 area&
o Some locali;e te Adamc:iewic; artery !reo!eratively wit C5, Scan or
MRA"
o some use somatosensory evo:ed !otentials 0 SB's1 or motor,evo:ed
!otentials 0 MB's1 monitoring to ascertain wic islands of intercostals or
individual arteries to reattac&
2ntercostal arteries can .e reattaced
directly to te graft" troug an individual .y!asses or
wit te use of an o.li>ue distal aortic transection wit
!reservation of te !osterior wall of te aneurysm
Cere.ros!inal fluid drainageC
age 22F
o 2n intrao!erative !eriod and e/tending for several days after te o!eration
o su!!orted .y a Systematic Review of te literature&
o Safi et al tecni>ue" a constant !ressure of )0mm?g is maintained&
?y!otermiaC
o Selective cooling of te s!inal cordC
o 2nfusion of *0 ml of iced saline into te e!idural s!ace for E0 min .efore
aortic clam!ing&
o tecni>ue was not consistently !roven as effective&
o te goal is to decrease te tem!erature and decrease meta.olism" 5?US

e/tending te !eriod of iscemic tolerance&
o y!otermia reduces te loss of A5' stores wit earlier resolution of lactic
acidosis&
'rotection of tissue damage from iscemia may also reduce
re!erfusion in4ury&
-it te use of te eat e/canger" various degrees of y!otermia
can .e acieved 0e&g& 28f C" EEf C1&
'armacologic agentsC
o Nalo/one during s!inal cord iscemia" steroids and !a!averine& 5ese
tera!ies were not !roven effective&
279.,leeding during &AA/ cause:
?y!otermia
Coag factor e/austion
o Aiver y!o!erfusion
o 'ost .leeding
o Aong OR time
?ence" warm u!" .e >uic:" !erfuse liver" re!lace coag factors 066'" cryo1" give volume&
280.%"en s"ould we (O& co*er SCA in t"oracic endografting?
'rominentLdominant Verte.ral on te A
A2MA graft is !resent
age 22*
B/tensive coverage of te decending torasic aorta is !lannedH i&e& 5%,A)
'rev AAA re!air 0lum.ar and 2MA collaterals are gone1
AORTIC DISSECTION:
281.Aortic Dissection:
Acute dissectionC
o 5y!e AC all need re!air .y cardiac surgeon&
2f tere is concomitant mesenteric iscemia" 62J MBSBN5BR2C
2SC?BM2A )
st
M
o 5y!e 3C
aggressive !ressure controlLim!ulse control tera!y
surgery forC
ru!ture
e/!anding aneurysm 0i&e& near ru!ture1
.ranc occlusion
ig ris: of ru!ture
o Marfan
o #iam Q * cm
o Aong term steroid
failure of medical tera!y
o 0i&e& ru!tureLe/!ansionL.ranc occlusion1 manifested
.y ongoing ?5N" 'A2N
Cronic dissection wit aneurismal dilatation H same indications as for AAA
AsideC
Classification and management of aortic dissections&
age 22G
ClassificationC
Sandford 0S for sim!le1 H
A , ascending"
3 H descending
#e3a:ey classification 0# for difficult1
) origin in ascending" goes at least as far as te arc or furter
2 origin in ascending" limited to ascending
E a H origin in descending" limited to descending
E . H origin in descending" goes to a.dominal
E c H origin in descending" goes !ro/imally to arc
5reatment of ty!e 3C
Medical H
EC2 U AC3
More in men
less tan *0O !resent wit ?5N
im!ulse control wit 33Ldilators is mainstay
.etter survival rate wit medical tera!y 0istead trial" 2RA# registry1
goals of treatmentC
o Sta.ili;e e/tent of dissection
o Reduce intimal fla! mo.ility
o Relieve dynamic aortic .ranc o.stuction
age 22+
o #ecrease ris: of ru!ture
indications for surgery , only for com!lications
goals of surgical treatmentC
o 2nduce aortic remodeling troug 6A trom.osis
2ndications
o Recurrent !ain
o Ra!id aortic e/!ansion
o Ru!ture
RFO of acute !resentations"
20O during te course of disease
o 3ranc Vessel occlusion
Mal!erfusion seen in 2*,F0O of acute dissection
Most im!ortant source of M<M
#ynamic o.struction 80O
Static 20O
6alse lumenC A renal a
5rue lumenC R renal" visceral
o #iagnosis and management are usually delayed
*0,80O mortality if renal iscemia
8+O if mesenteric iscemia
mortality for o!en surgery for mal!erfusion Q 20O
o ?ence endovascular o!tion is attractive
reduced u!front M<M
.ut 2NS5BA# trial sowed same results for stent vs medical in
acute A#
EO medical )0O stent mortality at ) year" ! NON,
significant
Surgical O!tionsC
o O!en
Central aortic re!lacement H for ru!ture 0used very rarely1
O!en fenestration for .ranc occlusion 0used rarely1
'rinci!leC
o -ide resection of te dissected se!tum
B>uali;e flow troug .ot lumena
o %,)0
t
2C s!ace toracoa.domianal e/!osure
o Se!tectomy may .e e/tended into visceral vessels
2f small aortaL!oor flowLsus!ected osteal
o.struction
Resect se!tum
o 2ns!ectLtac: !eri,osteal intima
o 6enestrate to infrarenal level wit 5eflon !leget
o Re!lace infrarenal aorta wit distal dou.le,5eflon
!leget anastomosis
o Bndo
age 228
Bntry site sealing
Bndo fenestration
'ro.lem wit endoC
Bndovascular a!!roac only seals endoluminal source of
.leeding
Aarge vasa vasorum and intercostals may still contri.ute to
late ru!tureLgrowt
o Surveillance necessary
May not !rovide long,term survival .enefit
o 3ridge tera!y troug ru!tureLemergency situationD
6#A Kore 5AK trialC a!!lies to toracic aortic re!air
%om5+i%a(ion o5en s(en(
!ara!legia )FO EO
stro:e )0O *O
ru!ture 0O 0O
reintervention )0O FO
Note" Safi results cannot .e re!roduced .y most centers 0i&e& GO s!inal cord
iscemia witout ad4uncts and 2O wit1& Results in real world !ractice are
-ORSB&
ConclusionC
o 6or uncom!licated ty!e 3 H medical tera!y
o 6or com!licated ty!e 3 H consider e/!editious diagnosis and treatment
Ru!ture or com!lications will li:ely re>uire o!en re!air
Stent if local e/!ertiseLlogistics availa.le
26 significant comor.idities H consider stent
Stent entry !oint and enlarge true lumen if dynamic .ranc
o.struction& Consider fenestration if no outflow for 6A
Stent individual .rancesLor individual vessel orifice if static
o.struction
Consider o!en if failed
o Carefully follow cronic dissections for future 5AA
)FO at F years
F0O at + years
AORTOILIAC OCCLUSIVE DISEASE !AIOD"
282.Approac" to pt wit" AIOD:
2n A2O# setting" always as: re
age 22%
3uttoc: !ainLim!otence
3lueL!ainful toes
2CLR'Lulcer
o Claud distance
Management of R6
2f !t as AAA in addition to A2O#" ten addM
AAA stuffM
o B!i 0race" gender" age1
o Sym!toms 0a.do" .ac: !ain" distal ateroem.olism1
o ?ig !ro.a.ility ris: factors H smo:ing" li!ids" CA#" 6?
o Aow !ro.a.ility ris: factors H #M" #V5" N a.do imaging
o Ris: 6actor for re!airC M2" CVA" CR6" CO'#" ?5N" level of activity"
longevity assessment
283.Indication for nd to nd *s nd to Side for A,1:
o Bnd,to,Bnd A36 .y!ass configuration
#o tis wen B2A o!en and you can re!erfuse internal iliacs
3etter ?# configuration 0teoretical1
3etter tissue coverage
2ndicated for aneurismal aorticLiliac disease
Basier clam! !lacement
o Bnd,to,Side A36 .y!ass configurationC
-en !reservation flow is re>uired in te following systemsC
2MA flow
o colon is !reserved
iliac system flow
o occluded B2A
o if .y!ass occludes" !t is .ac: to original state" wit
residual iliac system function" allowing at least AIA
to .e done
accessory renal a& flow and orsesoe :idney
median sacral and lum.ar a& flow
o s!inal cord !reservation
Bnd to side teoretically as more ris: of aterem.olic com!lications and less
cances of im!otence&
Ouflow management for A36C
2f !rofunda is smallLdiseased AN# !t as distal ulcer" add distal .y!ass
'rofunda,!o!liteal collateral inde/ 0''C21
o 2f Q 0&* H !rofundo!lasty alone will not im!rove s/s
age 2E0
o 2f R0&2 H !rofundo!lasty alone is ade>uate
3est indications for !rofundo!lastyC
o Rest !ain and minimal tissue loss
o No #M
o 'atent distal !o! and outflow wit ''C2 R 0&2
'ossi.le configuration of a/femC
'atency de!ends on indication&
'atency of A36C %0O at * years" +0O at )0 years" EO !erio! mortality
A/illo,.i,fem !atencyC +0O at * years
A/illo,uni,femC *0O at * years
284.Indication for Axillo).i)fe!oral 7raft:
o A2O# in !ts wit CR252AA lim. iscemia not suita.le for A36C
'oor surgicalLmedical ris:
age 2E)
?ostile a.domen
o 5o revasculari;e lower e/tremities following removal of an infected graft
Aortic graft
One lim. of A36
6em,fem graft
o 5reating AB critical lim. iscemia following aortic ty!e 3 dissection
Com!licationsC
)& U!!er lim. iscemia
a& Steal
.& 5rom.osis wit U!!er B/tremity em.oli;ation
c& Anastomotic !seudoaneurysm
d& Arterial distortion causing :in:ingLtrom.osis
2& 3racial !le/us in4ury
Note" if anastomosis is made to )
st
!ortion of a/il artery" anastomotic disru!tion
wit sudden arm a.duction is less li:ely&
?emodynamic results of a/,fem MA= NO5 significantly im!rove claudication
distance&
5raditionally a/illo,3i,fem are considered to ave .etter !atency tan uni&
o ?owever" .est a/fem !atencies were o.tained for uni configuration
o Ruterford9s com!anion states tat may .e !atencies are e>uivalent&
285.&ypes of endarterecto!y@ Discuss aortic endarterecto!y
o Controlled arterial in4ury tat eals .y intimal re,growt
-y BA is !ossi.leD
o Cleavage !lane and end!oint is smootC
#isease is limited to initima and inner media
#isease is segmental
o Residual adventitiaLouter media resists dilation
Fon("aindi%a(ions (o enda"(e"e%(om$-
Aneursmal disease
5a:ayasu arteritis
Radiation arteritis
Medial calcificationL5ransmural calcification
o Multi!le adventitial defects !ost !rocedure
5wo ty!es of aterosclerotic involvementC
age 2E2
o 5y!e )C
mCfU2C)"
younger"
aorta" C2A
s!are B2A" C6A" outflow
o ty!e 2C
mCfU*C)
older
ty!e ) !lus outflow involvement"
Aterosclerosis occurs atC
o Origin of aortic .rances
o Sites of arterial fi/ation
o Sites of tur.ulence
5y!es of BAC
o )5en
o ;emi/%+osed 6"emo(e#
5wo longitudinal arteriotomies at te end and .eginning of te
vessel" develo! distal !oint first" ten go !ro/imal&
o E7("a%(ion EA
-it emostat" develo! !lane ten !ull out !la>ue
Antegrade H
for aorticL.ranc vessels
distal e/tent of !la>ue is 2#9d e/ternally .y !al!ation
Aterosclerosis is orificial and smootly ta!ers in te distal
vessel
Retrograde H
for C6ALB2A
!ro/imal end!oint is se!arated .y crusing te artery
distal end!oint is controlled wit tal:ing suture
o E&e"sion H
5ransect artery
Bvert
o ;e+e%(i&e
2 don9t understand tis one
Keneral guidelines for aortic BAC
o 32AA5BRAA BA to iliac .ifurcation for ty!e )" and to C6A for ty!e 2
o Bntire media removal ,Q leads to 2,* mm dilatation of te artery
May .e res!onsi.le for dura.ility of re!air
o Uno.structed outflow to !rofunda
age 2EE
286.Causes of A- co!!unications in*ol*ing aorta and its5
.ranc"es:
o Congenital H Vascular malformations
o Ac>uired
Ru5(u"e o' degene"a(i&e AAA 6M);T F)MM)J#
trauma 0low velocity !enetration1
iatrogenic
o renal 3/"
o s!ine OR H aortaL2VCLiliac damage
o mass ligation of s!lenicLrenal !edicle
erosion
o due to se!sisLaortitis
o tumor 0renal Ca" mesencimal tumor .tw AoL2VC1
287.Potential p"ysiologic and anato!ic conse2uences of a large
A-1:
o 5rauma to te endotelium
o ?emodynamic conse>uencesC
#ro! in total !eri!eral resistance
2ncreased central venous !ressure
#ro! in mean arterial !ressure
2ncreased eart rate and stro:e volume H increased cardiac
out!ut
2ncreased .lood volume
Kradually increased AVB#' and volume
Cardiac failure
288.Aortoca*al fistula:
o Commonest cause H ru!tured AAA
o Also see arto,renal vein
-on9t see infrarenal 2VC contrast
No leg edema
?ematuria H +2O" flan: !ain
o Clinical features
AcuteC
3ruitLtrill Q 2LE
AAALmass
C?6 Q )LF
#ecreased distal !ulses
Swollen lower e/tremity" venous ?5N Q )LE
?ematuria Q)LF
age 2EF
CronicC RARB
AB swelling
venous trom.osis
!erinealLemorroidal varices
ematuria
a.do .ruit
ig out!ut C?6
'eri!eral circulation steal
Role of BVARD
2n clearly decom!ensated C?6 !t" ig ris: for o!en" as a tem!ori;ing strategy may
consider BVARM
COMPLICATIONS
289.Cardiac and Respiratory Co!plications of *ascular surgery:
M2 6atal M2
Aortic surgery 2&2O )&FO
2nfrainguinal .y!ass FO )&8O
Carotid endarterectomy )O 0&FO
i&e& M2 for aorta 2O" .y!ass FO" CBA )O&&& ?alf of tese is fatalMMyocardial
iscemia may .e as common as 20,F0O&&&
Role of screeningC undefinedM
o CA# is !revalent" .ut rates of M2 are fairly low 0see ta.le
a.ove1
o Aterosclerosis does not occur wit most ?# significant
stenosis
Cardiac screening detect !rimarly ?# sig stenosis
o Most autors state ris: stratification is im!recise at .est
o Aong term .enefits of CA# revasculari;ation 0if it is !erformed1
may not a!!ly for !ts wit 'V#
o Revasculari;ation BVBN for emodynamically significant
lesions may not .e .etter tan aggressive medical management
CA'R2 0CA3K1 and COURAKB 0'C21 trials
5ere are no validated invasive or non,invasive metods to 2# !alues
tat are vulnera.le to disru!tion
?ence !reo! o!timi;ation sould aim at !la>ue sta.ili;ation
2t is agreed tere is role for S5A52NS in reduction of CV mortality
o $u!iter trial
age 2E*
3eta 3loc:ers are useful as well
o Caution" as tey may .e armful in some !ts 0'O2SB study1
-ell done negative !rovocative test ave ig N'V
o 'ositive test" owever" does not ave ig ''V
Res5"i"a(o"$-
Nosocomial !neumonia H leading cause of nosocomial infectious deat
o 't may develo! inanition !neumonitis
#e.ilitated" nutritionally de!leted" can9t clear secretions
Atelectasis ,Q !neumonia
Ris: 6actors H smo:ing" CO'#" o.esity" UR52" !oor ealt
Suit smo:ing at least ) mont aead
Routine CJR !reo! useless H
o )F"000 !ts reviewed ,Q in )F0 CJR a.normal"
o 2n only )F !t a.normal findings caused cange in management
Acute Res!riratory failureC y!o/ic" y!erca!nic" .ot
'revention of !ost o! !ro.lemsC
o 'revent atelectasis
o Minimi;e artificial ventilation
o Strict glucose control , SUBS52ONB# in recent reviewsM
290.Isc"e!ic neuropat"y:
o Aarge nerve H due to trom.osis" em.olism" in4ury
o Small nerve H 'AN" Reumatoid vasculitis" Curg,Strauss" -egener" #M
o Some say muscle is more susce!ti.le to iscemia tan nerve
o Acute iscemia H
if more tan 2F denervation H a/onal degeneration o' bo(h
m$e+ina(ed and non,myeliated nerves
o Cronic iscemia H
mos(+$ m$e+ina(ed n8 affected H de and re,myelination" edema&
o 5em!oral and functional effect on nerves in umans in not well defined&
o Sensory deficits" no #5R seen in *0O of !ts wit 'V#
o B/tent !ro!ortional to severity
o Stoc:ing and glove distri.ution" distal muscle wastingLwea:ness 0foot
,Q!ro/imal1
o ## H uremia" #M" drug" alcoolism& 3U5 in tese H distri.ution is
S=MMB5R2CAA" in iscemia H it is limited to most 'V# affected lim.
#iagnosisC
2f an:le !ressure Q*0mm" toe !ressure QE0 H diagnosis is unli:ely
Blectro!ysiologic studies
age 2EG
5reatment H
o re!erfuse"
o may e/!ect slow regeneration of nerve fi.ers and relief of
sym!toms
9s%hemi% mononeu"o5a(h$- due (o +a"ge &esse+ o%%+usion H
trom.osisLem.olusL'A#
o 'eroneal
o 5i.ial
o 6emoral
o Aum.osacral !le/usC
Motor and sensory
More tan one dermatome" several nerves
Arefle/ic flaccid lim.
#d H !oor recovery in teseM
s!inal
o S!astic" y!errefle/ive" e/tensor
!lantar res!onse" dissociated sensory
loss
Cauda e>uine
9s%hemi% monome+i% neu"o5a(h$ ,i(h &as%u+a" a%%ess su"ge"$C
o Ma4ority are dia.etics
o after antecu.ital fossa access
ma4or watersed area for vasa nervorum for all tree
nerves
o sym!toms witin minutesLours after access
o .ounding radial !ulse
o t/C ligate fistula
291.Co!plications of aortic surgery:
o ?emorrage
o #eat
o Ureter in4ury
o 2scemia
Myocardial
Colon
Renal
Aim.
cere.ral
s!inal
o 2nfectionC
'neumonia
wound
graft
age 2E+
o -ound related
Nerve in4ury
Non,ealing
SeromaLlym!ocele
o 2m!otenceLretrograde ed4aculation
o RecurrenceC
Kraft dilatation 0:nitted1
'seudoaneurysm
292.Strategy to !ini!i>e renal da!age during aortic cla!ping?
o Manitol H )2&* H 2* g .efore clam!ing
2ncrease urine flow volume
#ecrease effects of cortical !erfusion reduction
6ree radical scavenger
o 6luid load .efore clam!ing
o Iee! warm iscemia under F0 min
May reduce s!inal iscemia
Bffect on renal failure is less clear cut wit octo!us devices
o -or:s for ty!e ) and ty!e * 5AAA" wen you don9t
need to reconstruct renals
o Cold !erfusion wit *00 cc F degrees NS
-en antici!ating Q F* min clam! time
Bffects seen wit )0 degrees tem! lowering
o Avoid ateroemo.lism
Un!roven H do!amine" fenolda!am
293.Clinical c"aracteristics/ risk and diagnosis of isc"e!ic
colitis:
0&*,)0O" overall 2 O
o 2f loo:ed for aggressively" will find out in GO of elective cases
MecanismC
o 5rom.osis of intestinal arcaded due to y!otension
Unrecogni;ed y!ovolemia !erio!
o Bm.olisation of aneurismal contents
o 5raction in4ury
o 2na!!or!tiate 2MA ligation
Not from witin of aneu
Unrecogni;ed significance of 2MA wit celiacLSMA stenosis
o Use of !ressors
age 2E8
i&e& 4ust reim!lanting 2MA is NO5 going to solve all te !ro.lemsM
Barly !ost o! 02F,F8 1 H .loodyL.row diarrea in )LE of !ts
A.do !ainLdistentionLfeverLoliguriaLtrom.ocyto!eniaLleu:ocytosis
o #sC clinical !resentation !lus fle/ sig
?ig inde/ of sus!icion
2f sus!ect H sco!e" if more tan mucosa H ?artmann&
o R6 !redis!osing to colon iscemia
5ecni>ueC
2m!ro!er 2MA ligation H too distal
o 'articularly if meandering a& is !reserved
Aoss of internal iliacs
o Bm.oli;ation during mani!ulation
Retractor in4ury
o 5o collaterals
o 5o colon
O!erative !rocedureC
Ru!tured aneurysm
2ncreased J,clam! time
'erio! y!otensionLy!o!erfusion
'atientC
Old age
Comor.iditiesC
o 'revious colectomyLloss of collaterals
o 'rev rads
o SMALceliac artery disease
'ost o! Renal failure increases ris: of deat E fold 0to )*O1
Aung and eart !ro.lems increase ris: of deat 2 fold 0to )0O1
294.Colon isc"e!ia a*oidance after AAA repair:
o Assess 2MA .ac:.leeding H
re,im!lant if none or R F0 mm ?g .ac:!ressure
Aigate 2MA at orifice ,Q !reserve arc of Riolan
cec: wit tonometric colonic mucosa !?C sould .e Q G&8G
o 'reserve internal iliacsC
Avoid em.olus"
don9t ligate
o 'reserver !rofunda collaterals
o Avoid mecanical mesentery in4ury H e&g&wit retraction
o 3etter anestesiaC
no anemiaLy!otensionLy!otermia
o 3etter tecni>ueC
minimal cross clam! time
age 2E%
295.How to pre*ent sexual disfuntion wit" aortic surgery:
o #OCUMBN5 'RBO'
o R sided dissection of aortoiliac segment
o Minimal division of longitudinal !eriartic tissues to te left of te infrarenal
aorta
o #on9t dissect at te .ase of 2MA
o #on9t cut tissues over A C2A
o Maintain internal iliacs
o Aigate 2MA from witin
o Use of retro!eritoneal a!!roac may .e .eneficial
Aside" if done wit !recautions" aortoiliac reconstruction 0for A2O#1 may restore !otency
in 2*O of !ts& ?owever" if no !recautions are ta:en" incidence of im!otence is close to
)00O even among tose tat were !otent&
296.How to i!pro*e pel*ic circulation:
Correct inflow H aorticLiliac disease
2m!rove internal iliac
Angio!lasty
Bndarterectomy
3y!ass
su!!ort collateralsC
o 2MA reim!lant
o 'rofundo!lasty
Cec: for !atency of arc or Riolan
o 2MA reim!lantaion if !oor collaterals
297.Incidence of co!plications wit" different type of access:
o A/illary H *,)*O
o 5ranslum.ar H *,)*O
o 6emoral H ),)0O
298.Pseudoaneurys! for!ation: causes
o no !revious surgery
infection due to 2V drug use
trauma
!ercutaneous intervention H 3= 6AR te most common
cause of 'A overallM
o !rev surgery" i&e& anastomotic , 2
nd
most common
+0O degenerative"
2*O infection"
* O suture .rea:
age 2F0
2n general" causes areM&
disease related
o increased outflow resistance due to AsC !rogression
arterial wall wea:ness related
o !rogression of AsC
o infection
o aggressive Bndarterectomy
o disru!tion of vasa,vasorum
!rostetic graft related
o com!liance mismatc
o graft dilatation and deterioration
anastomosis related
o tension due to !osition 0groinLfle/1
o tension due to graft sortness
o uneven tension at anastomosis
sort graft
native artery elongation
o suture tear
o so U relating to te artery" graft" suture line" infection" !ysical stress" tec
errors&&
o wen to fi/D
Aortic H at F cm
2liac H at E&* cm
C6A H at 2&* cm
wen sym!tomatic
#uring re!air" loo: for te sign of infectionM if infected" see
infected graft notes&
299.Post Angio pseudoaneurys!: w"y?
o 2nterventional rater ten diagnostic !rocedure
o Multi!le cateter e/cange
o 5ecnical errorsLine/!erience
o 'eri,interventional Multi!le 0e&g& loveno/" !lavi/" warfarin1 anticoagulation
o 6emale gender
o Q G0 yoa
o Aac: of closure device
o 'oor selection of access
300.Intraartearial drug in<ection + !ec"anis! of in<ury 3 tx
Me%hanisms-
o Vessel o.struction wit !articles
o #irect endotelial damage wit trom.osis H venous and arterial
age 2F)
o ?y!ersensitivity vasculitis
o Vasos!asm
F+ini%a+ mani'es(a(ions-
)& 5raumatic com!licationsC
a& AV6
.& !seudoaneurysm
2& 2nfectious com!licationsC
a& 2nfected !seudoaneurysm or arteritis
.& Mycotic !ulmonary aneurymsC dys!nea" cyanosis" emo!tysis
c& endocarditis
E& 5rom.otic com!lications leading to iscemiaC
a& 2n situ trom.osis at in4ection site
.& distal em.oli;ation ,Q iscemia
F& 'armacologic effects of te drugsC
a& NOM2LM2 wit Cocaine
5era!yC
Angiogram to 2# local arterial in4ury
)& intimal fla!"
2& AV6"
E& !seudoaneurysm"
F& trom.osis"
*& distal vasos!asm
'armacologic tera!yC
)& Vasodilators 0intra,arterial !a!averin" tola;oline 02*,*0 mg1 iv severe vasos!asm
2& Anticoagulants H e!arin" de/tran F0
2f infected !seudoaneurysm H treat as infected graft&
301.%"at increases contrast nep"ropat"y?
o Advanced age
o 're,e/isting CR6
o ?y!ovolemia
o ?y!erosmolar agents
o #M
o Aarge volume of contrast
o Re!eat doses of contrast
o Co,ingested ne!roto/in
ACB2
ASA
age 2F2
aminoglycosides
o Multi!le myeloma
o ?eavy !roteinuria
o ?ig osmolarity agents
Note" non,inonic agents ave similar incidence of adverse side effects as ionic&&
302.Ad*antages of low os!olarity contrast to co!pared to "ig"?
o Reduces ris: of severe allergic reactions .y 80O
o Reduces !ost,venogra!y !le.itis 0less endo in4ury1
o Aess ne!roto/ic
303.7adopentate Di!eglu!ine aka CO
9?
Aow ris: of renal disfunction" .ut !oor resolution& Can cause mesenteric iscemia wit gas
em.olism&
304.Co!plications of .lood transfusion:
o fatal A3O incom!ati.ility )C million
o non,fatal A3O incom!ati.ility )C2*0"000
o fe.rile reaction )C)00
o transfusion related lung in4ury 0rare1
o KV?# in immuno su!!ressed
o 2nfectionsC
viral ?e! 3" C" ?2V" ?5AV
.acterial contamination 0!latelets1
Cagas9 disease
305.Difference .etween sero!a and ly!p"ocele?
o Aym!ocele as feeding lym! cannel& -en e/cising" need to ligate it&
Surgery is indicated for enlarging AC or ones close to te !rostetic graft
0ris: of infection form ad4acent AN1& 'rior to tis" legs u!" com!ression"
!revention of infection
o Com!lications of cronic lym! lea:C
Malnutrtition
Aym!ocyto!enia
Anemia
2nfection of underlying graft
o 2f cose to investigate H * ml of isosulfan .lue .etween toes"
o for mesenteric lym!lea:s H F !reo! 2F o; of wi!!ing cream via NK&
o 'ercutaneous treatmentC talc" alcool" .leomycin" fi.rin H effective" coming
into foreground
age 2FE
INFECTED GRAFT
306.(ati*e *ascular *essel infection:

MTF)T9F
AJEHRT;M
M9FR)<9AL
ARTER9T9;
9JDEFT9)J
)D
EO9;T9JI
AJEHRT;M
.);T/TRAHMAT9F
9JDEFTED DAL;E
AJEHRT;M
Btiology Bndocarditis 3acteremia 3acteremia Narcotic addiction" 5rauma
Age E0,*0 Q*0 Q*0 RE0
2ncidence Rare Common Unusual Very common
Aocation Aorta Aterosclerotic 2nfrarenal 6emoral
Visceral Aortoiliac Aorta Carotid
2ntracranial 2ntimal defects
'eri!eral
Micro.iology Kram,!ositive
cocci
Salmonella Staphylococcus Staphylococcus aureus
Oters Oters 'olymicro.ial
Mortality 2*O +*O %0O *O
'ost traumatic infected false aneurysm H MC
Micro.ial arteritis wit aneurysm , common
2nfected !re,e/isting aneurysm , unusual
Mycotic aneu 0!reanti.iotic Q%0O" now R)0O1 RARB
Does no( in%+ude-
in'e%(ion '"om %on(iguous sou"%e
ao"(o/en(e"i% 'is(u+a
&as%u+a" s$n(he(i% g"a'( in'e%(ion
18 M$%o(i%- mo"(a+i($ 3MK
#ue to endocarditis
E0,*0 yoa
AocationC
o 6emoral 8%O
o U!!er e/t )EO
o aorta )2O
o Cranial FO
o SMA
o -ere H site of .ifurcations" AV6" coarctations&
3ugsC
age 2FF
if no 2V#U H Stre! Viridance 22O" SA 20O
2V#U H SA EGO" 's& Au )GO
2. Mi%"obia+ a"(e"i(is ,i(h aneu- mo"(a+i($ LMK
*0 yoa
#ue to .acteremia
More common tan mycotic
At te site of Aterosclerosis
Most commonly aorta 0EC) com!ared to !eri!eral sites1
LLK o' a++ in'e%(ed ao"(oi+ia% aneu"$sm:
MC B&Coli" ;a+mone++a 2 5"edis5osi(ion (o Ao"(a" SA
Also" A2#S" CR6Lemodyalysis !ts are susce!ti.le
Q8 9n'e%(ed 5"e/e7is(ing aneu- N0K mo"(a+i($
)*O of AAA grow stuff H un:nown significance
o E8O ru!tured
o )EO sym!tomatic
o %O elective
3ugsC
o Sta! H F)O , St& B!i is most common
48 .os( ("auma(i% in'e%(ed- M K mo"(a+i($
Most common" lowest mortality
2V drug use
'ost !ercutaneous !rocedure H Ris: 6actorsC
o Aong !rocedure
o Re!eat cat
o #ifficult access
o Arterial seat in Q2F
o C?6
o Use of angioseal
Most Common microorganism H Sta! Aureus&
o 6ungal RARB H in #M and immunosu!!ressed&
Ruterford9s com!anion states tat unless !urulence and gross uncontrolled
infection" always try to revasculari;e wit autologous in situ re!air AN# muscle
fla! 0Sartorius1
'resentationC difficult to detect&
o 6ever of un:nown origin
o 'ositive .lood culture
o Brosion of lum.ar verte.rae
o 6emale se/
o 'resence of uncalcified aneurysms
o 6irst !resentation of an aneurysm after .acterial se!sis
age 2F*
2f see aortic infection H li:ely micro.ial arteritis leading to aneurysm
2f see femoral infection H li:ely infected !seudoaneurysm" second !ossi.ility , mycotic
aneurysm
Aa.C
Negative .lood cultures" intrao!erative Kram stain
o ARB NO5 sensitive enoug to e/clude ds
o 2n ru!tured AAAC
3lood culture is !ositive in G%O " Kram stain H in *0O
o only ))O Kram stain is !ositive in non,ru!tured AAA
Bven in aneurysm wall culture was found to .e !ositive in only %2OM
o !&)*88
#SA a!!earanceC
o saccualr aneu in normal vessel"
o multilo.ulated aneu"
o eccentric aneu wit narrow nec:
Aum.ar osteomyelitis
2ndium ,))) la.eled -3C el!ful for !rostetic graft infection" NO5 infected
aneuM
9n%on("o&e"(ib+e 5"in%i5+es o' ("ea(men(-
18 Fon("o+ hemo""hage
38 Fon'i"m ds- g"am, %u+(u"e 'o" ba%(e"ia'ungiT<
Q8 )5e"a(i&e %on("o+ o' se5sis- "ese%(, deb"ide, ab7 i""iga(ion, d"ain
48 .os( o5 ,ound %a"e- d"essing %hange, "e5ea( deb"idemen(s
M8 Long (e"m ab7
6. Fonside" "e%ons("u%(ion (h"ough non/in'e%(ed 'ie+d- THE )JLT TEJEJT
).EJ T) CON5ROVBRS=M
307.C& findings for infected prost"etic graft:
o 6luid around graft
o Kas around graft
o 'seudoaneurysm
o Soft tissue stranding
o Ad4acent verte.ral osteomyelitis
o ?ydrone!rosis
o Retro!eritoneal a.scess
308.Risk 1actors predisposing to graft infection:
o 3acterial contamination of te graft
'erio!erative contamination
?ematogenous s!read from remote source
age 2FG
Brosion of graft into KULK2 tract
Contiguous !rocess
o Ris: factors for contaminationC
'rocedure relatedC
o Bmergency surgery
o Remote infection
o 'rolonged !reo!L!ost o! stay
o O!erative !articulars
Reo!erative !rocedure
Simultaneous K2 !rocedure
CrusLRoug tissue andling
ematomas
Contact .etween s:in and graft
o 'ost o! wound infection
Altered ost defenseC
o Advanced age
o 6emale gender
o As!irin use 0ematoma1
o Malnutrition
o Aeuco!enia
o Malignancy
o Steroids
o Cemo
o #M
o CR6
o Autoimmune disease
309.Pre*ention of graft infection:
o Minimi;e !reo! stay 0to reduce coloni;ation .y resistant flora1
o 5reat remote infection !rior to surgery
o Antise!tic !reo! sower 0Cocrane" 20081
o 2mmediate !reo! saving 0Cocrane" 20081
o 'ro!ylactic a./ !reo!
o Meticulous sterile surgical tecni>ue
Autogenous tissues for .y!ass or endarterectomy
Kentle tissue andling" no crus
2odine im!regnated dra!es to limit contact .tw s:in < graft
Meticulous emostasis H no ematomasLlym!lea:s
Meticulous s:in closure
Rifam!in .onded graft 0Cocrane" 20081
Close suction drain 0Cocrane" 20081
Avoid simultaneous K2 !rocedures
o Barly recognitionLaggressive treatment of wound infections
age 2F+
o Su!!ort nutrition
310.In*estigation of pt wit" draining R groin wound post A,1
o C3C" BSR" CR'
se!sis" inflmmatory state
o 3UNLCR" lytes"
o: for contrast" need for fluid resusc
o 3lood culture" wound culture
to 2# microorganism
o Kroin USLdu!le/
to see if graft !atent" !seudoaneurysm
o C5A a.doL#SA and runoff
fluidLgas around graft
vascular reconstructive o!tions
o 2ndium la.eled -3C scan
indirect evidence of infection
311.Infected A,1 graft: Draining sinus in groin post A,1:
approac" +
o Concerned wit graft infection
o Review old OR notes and indications
o Review current status of 'V# and need for revasc
o Culture .lood and site
o Confirm !atency of graft 0dysfunctional graft1
o 2mage H USLC5Langio H i&e& esta.lis te !resence ofM
2nvolvement of anastomosis
'seudoaneurysm
e/tent of involvement
undrained fluid collectionLa.scess
reconstructive !otential
o 5reatmentC
Bradicate infection
Anti.ioticsC
o 3road s!ectrum anti.iotics to start wit
o Narrow to culture s!ecific a./ wen !atogen is
:nown
o Continue a./ long term
Control source of infectionC
o Remove infected graft
o #e.ride to ealty tissue
o 6la! tissue coverageLdrainLleave o!en
age 2F8
Reconstruction of distal circulation
Aimited to groin onlyD
Can !rofundaLS6A .ifurcation .e reconstructedD
Can graft .e !reservedD
Can we consider insitu reconstructionD
2f infection is limited to groin" main .ody may .e !reserved&
Circulation may .e reconstructedC
via o.turator .y!ass to S6AL!o! OR fem,fem 0medial tunneling1
o if only one lim. is involved and main .ody is o:M
Via A/,S6AL!rofundaL!o! tunneling laterally in te area away from te
site of infection
5oraco,S6AL!rofundaL!o!
-eird<wonderful H carotid !o!liteal .y!ass
2f infection reaces main .ody .ifurcation" an entire graft must come out& 6irst"
revasculari;e wit A/,distal fem" ten remove a.dominal !ortion of te graft" de.ride
aorta" get anterior s!inal ligament and omental !edicle to .olster aortic stum!& 6inally"
remove groin lim.s and oversew native vessels&
312.Classification of graft infection:
i&e& 3untC
'0 H cavitary graft infection" AAA and A36
') H e/tra,anatomic
'2 H infection of fem !ortion of A36 or cervical of aortoLcarotid
age 2F%
'E H !atc angio!lasty infection
KB erosion
KB fistula
Aortic stum!
313.C& findings of aortoenteric fistula:
o 'eriaortic gas or fluid
o 'ro/imal !seudoaneurysm formation
o 3owel wall tic:ening
o Retro!eritoneal stranding
o 'lane .etween duodenum and aorta o.literated
o 2V contrast seen in .owel
Note" tat .arium enema or .arium K2 contrast is contraindicated in AB6 H will o.scure
!icture and may cause retro!eritoneal s!illageLinfectionLse!sis&
314.Selection of pts for infected graft preser*ation:
o Not #acron
o No anastomotic involvement
o No se!sis
o No !seudamonas
NoteC #acron may still .e !reserved .ut less cance of success
com!ared to '56B
?owC
KeneralC o!timi;e eart" lungs" :idney" nutrition" wor: out revasculari;ation
!otential" ma! veins
'retreat wit E days of .road s!ectrum iv a./
#e.ride" irrigate in OR
Sterili;e woundC
o VancLgent .eads canged every + days
o )O iodine dressing 52#
Continue culture s!ecific a./
Sartorius muscle fla! coverage
Aong term !o anti.iotics
On e/am" .e careful wit !resenting !reservation of graft as a first coice" list it as one of
te o!tions only&
315.Selection of infected graft for insitu replace!ent:
o No se!sis
No !ositive .lood and tissue cultures
age 2*0
3iofilm culture !ositive for Sta! B!i
o No graft,enteric, fistula
?owC
2v a./ .road range
Sterili;e field
o #e.ride
o 2rrigate
o VancLgent .eads > + days
o )O iodine saline dressing
Confirm sterili;ation on culture
2n situ '56B, rifam!in soa:ed graft vs fem,fem
o Kentamicin im!regnated trom.in glue on anastomosis
Sartorius muscle fla! for groin
G monts iv a./ ten E monts !o anti.iotics
On e/am" .e careful wit !resenting insitu re!lacement of infected graft as a first coice"
list it as one of te o!tions only&
316. Results of aortic graft infection treat!ent:
Staged 0a/,fem first" ten in 2 days e/cision of graft1 is .est
#on9t use !ledgets on aortic stum! H infection nidus
2f a/,fem got infected" ten consider need for revascM
o if iscemic" ten may do toracic,fem .y!ass&
o 2f see mon!asic signal or F0 mm ?g at an:le" may consider to
forgo revasculari;ation
Mortality Am!utation Re,infection Survival Q
year
B/,situ .y!ass <
e/cision
20O )*O )0O 80O
2n,situ wit vein )0O *O )O 80O
Rifam!in '56B )0O *O )*O 8*O
Advantages of in,inisitu vs e/,situC
Less 5e"io5 mo"(a+i($ 610K &s 30K#
Less am5u(a(ions 6MK &s 1MK#
;imi+a" su"&i&a+ o&e"a++
317. Aorto)enteric fistula:
'rimary
o Aess common overall
o #egenerative sterile AAA e/!ansion most common in tis category
age 2*)
o #uodenal Ulcer 0second MC1
o Cancer" 63
Secondary
o 2nfection at suture line H
leads to !seudoaneurysm" e/!ansion" !ressure on te duodenum
o 2nfection li:ely latent H
s:in flora tat gets activated wit di!s in immunoco!metence 0!&
%0F1
o 'ulsatile !ressure
o #uodenum H in4ury during 5ransa.dominal mo.ili;ation
2nitial fistulae were at .ody of te grafts wen omografts were
used
ManifestationC
o K2 .leed" se!sis" a.do !ain H rare
K2 .leed H seen in 2)O of all AAA re!airs"
only 0&FO of all tese .leeds will ave AB6
o 6everLmalaise
o Se!tic em.oli
Common H 2+O" lead toC
Multifocal ostemyelitis and cellulitis
?y!ertro!ic osteoartro!aty
o A.do !ain due to !seudoaneurysm !ressure
Bvaluation
o ?/ and !ysical
UK2 .leed" lower K2 .leed 0aotoa!!endicial fistulaLto lim.1" AAA
re!air" systemic signs" a.do mass" AB multifocal cellulitis
o BK# H to rLo oter source of .leed" to F
t
!ortion
o C5
o 2ndium ))) scan
o Angio to define run off and renal a& location
o 2n alf te cases need to e/!lore in OR
5reatment is surgicalC
o 2d !resence of active emorrage
o Classify AB6 H !rimary vs secondary
o 2ndication for re!airC A2O# vs aneurysm
2f BtS A2O# H ten ta:e down and !atcing of te aortotomy is an
attractive o!tionM
o B/tent of se!sis
o KoalsC
Save life" ten !reserve lim.& ?owC
Control emorrage
Re!air K2 tract
Control infection
age 2*2
Maintain ade>uate distal !erfusion
SurgeryC #B5A2AB# consent firstC onest" realistic" detailedM
o ;%ena"io 1- 5( is b+eeding-
linesLa./Lemergent surgery
5' vs retro!eritoneal
R' if difficult nec: is antici!ated"
o can9t see R C2A" R renal and can9t do Rigt a/,fem
Su!raceliac control of .leeding first H !lace clam! .ut don9t close it
until needed
Medial visceral rotation vs troug te crus
#istal control
'eel of duodenum" !ut a stitc to control s!illage if needed
ResectLde.ride infected aorta
#ecide on in,situ vs e/tra,anatomic
Re!air duodenumC
'rimary" rou/,en,y" PL, gastrostomy" 4e4unostomy
Assess e/tremities
2f mono!asic signalLQF0mm ?g at an:les may forego
revasc
o ;%ena"io 3- Jo b+eeding-
Confirm diagnosis AN# rule out K2 .leed 0oter sourcesss1
C5" BK#" tagged R3C" -3C scan
Consider e/tra,anatomic revasculari;ation first !rior to e/cision&
o 2f !rimary AB6 H only E0O are infected
May consider in,situ re!air wit life long surveylance
'ossi.le if minimal retro!eritoneal soiling and no se!sis
Allows for sim!le dura.le revasculari;ation
Uncertain long term !otential for infection
Safer o!tion is an e/tra,anatomic re!air
o 3acterial seeding in AB6 can occur in a.out 2*O of all te BA3M
6or ty!ical synttic graft" te ris: is a.out )0O&&&&
o Com!osite e/tra,anatomic .y!ass H
S6V to infected groins" !rostetic to a/illaM any meritD '&%)0
o Role of BVARD
AimitedM may .e considered for !rimary
AB6 after BVAR as .een descri.ed as wellM
o Results of Aorto,Bneric fistulae re!airC
Natural istory H .leeding" se!sis" deat
age 2*E
O!erative re!air ,E0,F0O mortality
Am!utation )0O
E year survival *0O
TRAUMA:
318.Carotid a@ in<ury and neurologic deficit@ %"en to fix?
o Jeu"o+ogi%a++$ as$m5(oma(i%, no o%%+usion , fi/
o Jeu"o as$m5(om(i%, o%%+usion
Some may say 7tan: you luc:y stars8
Ruterford states re!air to !revent delayed com!lications
AV6
5rom.us !ro!agation
!seudoaneurysm
Anticoagulate and don9t fi/ itM
o Comatose" no occlusion H .e careful to rLo oter causes of coma
o Foma(ose, o%%+usion , fi/
2nitial anectodal re!orts of converting iscemic stro:e to
emorragic&
Concerns a.out distal em.oli;aiont during carotid re!air are
unfounded according to Ruterford
Controversion area .ut Ruterford suggests to e/!lore
5ry to resta.lis .ac: flow wit u! to te level of te s:ull fogart
re,!erfuse if .ac:.leeding
2f can9t .ac:.leed or too e/tensive H ligate" PL, anticoagulate&
All availa.le evidence suggests o5(ima+ neu"o+ogi% ou(%omes a"e
ob(ained ,i(h o5e"a(i&e "e5ai" be%ause mos( de'i%i(s "emain
un%hanged o" im5"o&e8
Can9t always discern te etiology of comaC alcool" meta.olic"
durgs" soc:" vs vascular in4ury
Comatous !ts mortality O!timal normal outcome
28 !ts ligated G0O )*O
F2 !ts re!erfused 2*O *0O
!&)00%
Minor carotid in4uries can .e followed wit angioL#US
319.&reat!ent of .lunt carotid in<ury:
o Carotid,cavernous sinus fistulae H .alloon occlusion tecni>ue
age 2*F
o #issection H AC alone" rigorous follow u!
%0O recovery to normal function if AC started .efore neuro
deficit" F0O after te onset&
Survey for dilatationC
o G2O reverted to normal
o 2%O !rogressed to !seudoaneurysm
Stents H controversial
o 'seudoaneurysms
Surgical re!air if easy to access or sim!le
Oterwise AC" ligate"
Rarely BC,2CLcervical !etrous 2CA .y!ass
o Verte.ral artery in4uryC
2f !enetrating and e/sanguinatingC
o 5reat it wit ligationC very little downsideM
o EO cance of .rainstem stro:e if A is ligated" 2O if
rigt
o May try endo to occlude
2f .luntLoccludedLAV6L!seudoaneurysmC
o O.serve wit AC" follow wit angio
o Consider endo occlusion 0trom.osed artery in fact
may .e com!letely transected1&
o 5is will address concerns reC re.leeding
2f dissection H usually see in VE segment" ),2L*2 !ost
traumaC 80,%0O !resent as !osterior circulation infractM
'&)0)2
320.C"est *ascular trau!a:
o Ascending aorta and arc H re>uire full cardio!ulmonary .y!ass"
y!otermia and cardio!legic arrest
AsideC arc vessels may .e reconstructed wit side .iting
clam! to assending aorta and a .y!ass
o #istal aortaC
Clam! and sew
Off load eartC
Atrio,femoral .y!ass 0Most common1
A/illo,femoral 0time,consuming1
6ull cardio!ulmonary .y!ss 0used rarely1
o Aortic trauma re!air general !ointsC
're,warm room and fluids to F0 degrees
'ro/ control .tw A CCA and A SCA
-atc out for vagus and toracic duct
A verte.ral artery ta:es off arc in 8O of cases
age 2**
#o not de.ride aorta
#o not sacrifice intercostals
Move clam! closer to in4ury
6ine suture and :nitted graft
6or grafts ta:ing off ascending aorta" use single lim." multi!le if
necessary
'remanifactured .ifurcated are too .ul:y" may not fit in
anterior mediastinumM
Use .ovine !ericardium to cover tis
Mid+ine s(e"no(om$- he+5'u+ 5oin(s
o S:in from Sternal notc to /y!oid
o #evelo! retrasternal !lane a.ove and .elow" no need to connect tese
o ASI anestesia to deflate lungs to minimi;e cance of !nemo
o Oscilating saw
o #ivide tymus
o A .racioce!alic veinC
'reserve
ligate its9 tyroid tri.utaries
will allow mo.ili;ation of tis vessel&
An(e"io" (ho"a%(om$- 'o" sub%+a&ian e75osu"e
o Avoid R sided central lines H may cause !neumo H
won9t .e a.le to do single lung ventilation
o #ou.le lumen B5 tu.e
o Su!ine" roll under A soulder and i! to .ring cest u! 20 degrees
o A infra!ectoral incision
o 2# *
t
ri." go a.ove it H F
t
intercostal s!ace
o Ri. s!reader H may need to divide internal mammary aLv
o #eflate lung" !us it down
o 2# arc under mediastinal !leura
o 2ncise it" !reserving A vagus nerve coursing anterolaterally over origin or
ASA
o 5oracic duct is !osteromedial , !reserve
L .os(e"o/+a(e"a+ (ho"a%o(om$- 'o" des%ending ao"(a e75osu"e
o 3ean .ag" stra! i!s"
o 5rue lateral !ostion" roll under R a/illa" A arm over Mayo stand
o 2ncision from .elow A ni!!le to ) inc .elow ti! of sca!ular
o #ivide serratus ant" lats" tra!e;ius H slide soulder girdle u!
o F
t
2CS for middle descending aorta" G
t
2CS for distal
o Verify 2CS from a.ove .y counting
o 'rotect !renic and vagus nerves coursing over arc
age 2*G
321.Radiograp"ic clues to potential .lunt aortic in<ury:
o Aoss of te sadow of te aorto!ulmonary :no.
more s!ecific tan wide mediastinum
o Aoss of !areverte.ral stri!e
o Aoss of aorto!ulmonary window
o #e!ression of te AMS3 Q )F0 degrees
o #eviation of nasogastric tu.e
o Aateral dis!lacement of tracea
o A!ical ematoma
o -ide midiastinum Q 8 cm
o Massive left ematora/
o 6racture of te sternum" sca!ula" multi!le left ri.s" clavicle" !elvis
o 3lunt in4ury to te dia!ragm
322.#ost co!!on .lunt *ascular t"oracic in<uries:
#escending aorta distal to ASA
2nnominate artery
323.Conser*ati*e treat!ent of t"oracic aortic in<uries:
o 5ree categories in multi!ly in4ured !ts
Massive in4uries" e/sanguination on site
Unsta.le during trans!ort" transient res!ondersC
ig mortality rate due to multisystem trauma
?# sta.le" confined mediastinal ematomaC
tese can .e o.served&
#eat is due to ead in4ury
o 2f cosen to o.serve" use
2m!ulse reduction tera!y
MA' at minimum 0R%01
Bnsure sta.ility of mediastinal ematoma on serial imaging
't is fully informed reC ris: and .enefits
Management during delay is su!ervised .y vascular surgeon
o Can delay u! to +2
fi.rinous organi;ation of mediastinal clot ta:es !lace
324. A.do!inal *ascular trau!a:
age 2*+
IoreanLveietnam war H EO
CivilianC
o 'enetratingC
gun sot H )FO" sta. )0O
o .lunt EO
MC renal" ten SMA
Retro!eritoneal ematomaC wen to e/!lore

)& B/!lore all !enetrating
a8 E7%e5(ion 2 s(ab+e 5e"ine5h"i% J)T in&o+&ing (he hi+um
2& 3luntC e/!lore only if
Aea:ing
B/!anding 0some say only RA'2#A= e/!anding1
'ulsatile
'araduodenal
Roo( o' mesen(e"$ 6i8e8 ;MA# .LH; is%hemi% bo,e+
Yone EC
o 2ntra!eritoneal 3ladder in4ury
o male uretral in4ury
o !ulseless leg
asi"e:
#l!nt in$!ry to the ilia artery % lea"s to thro&#osis "!e to streth.
'(P)O*' only if:
+ntraperitoneal lea,
'-pan"in.
/#sent or "i&inishe" fe&oral p!lse
p. 1039
On e-a& it is safe to si&ply "o fe&0fe&1 if there is no nee" to e-plore the a#"o&en 2an"
) he&ato&a34. 5owe6er1 in sta#le in"i6i"!al1 *!therfor" s!..ests e-ploration an"1
possi#ly1 iliofe&oral #ypass35e&o"yna&i an" pateny res!lt of fe&0fe& in a yo!n.
pt is 7/* inferior to iliofe&. 7or +liofe& % !se 879 if onta&ination3 :!t for e-a&
p!rpose1 "o not "o iliofe& % will #e too onta&inate" for the prostheti1 an" will ta,e
too lon. to .et 879.
Une/!lored ematomas are to .e followed .y #o!!ler and #o!!ler&
Bnteric s!illage is not contraindication to !rosteticsC
so consider e/trananatomic .y!ass only in case of !urulent
!eritonitis and infected graft 0Ruterford1
Multi!le trauma e/!erience suggests safety of !rostetics even in
te face of entric contamination& Cover tis wit grafts
Su!ra mesocolic a&control H
age 2*8
o A visceral rotation" dia!ragmatic control" A cest
2nframesocolic ,
o 5ransverse colon reflected ce!alad" small .owel to te R&
SMA H retro!ancreatic !ortion 0may transect nec:" or su!raceliac !ro/imal control1"
infra!ancreatic !ortion 0retract !ancreas u!1&
-en to ligate aortic .rancesC
SMA H only in te !resence of necrotic .owel AN# only at te origin H a.ove
gastroduodenal and inferior !ancreatico,duodenal arcade&
o Blsewere H ig incidence of .owel iscemia&
Celiac H o: if SMA is o:
C?A H !ro/imal to ta:e off of K#A&
A renal vein ligation at 2VC is tolerated well"
R renal vein ligation is always followed .y ne!rectomy&
NBVBR ligate C2A or B2A witout reconstruction" even in !ts in critical condition&
o 'lace tem!orary sunt if necessary&
May ligate iliac veins H
o 2f re!air will result in stenosis Q *0O
o 'ro!ylactic fasciotomies are controversial
o No role for com!le/ s!iral graft reconstructions
2VC H may ligate if infrarenal
o -ra! and elevate legsM
Renal a& in4ury H
revasculari;e if
o witin G " if single or
o witin 20 if SOAB :idney in4ury or .ilateral damage
autorities vary on e/act timing
Success of revasculari;ation is !oor at a.out E0O&&&
o in )2,*0O of revasculari;ed !ts y!ertension develo!s
o 2f non,revasculari;ed" ?5N develo!s in E0,F0O witin ) mont to a
year" mean E mont
Some recommend surgery for Renal Artery re!air only inC
o 2ntrao!erative identification of renal artery in4ury
o Sta.le !t
o Solitary :idney !resent or .ilateral in4ury
o 5e rest H monitor for y!ertensionM
age 2*%
325.xtre!ity trau!a notes:
o Most common ty!e of vascular trauma 080O of all ty!es1
'enetrating %0O" .lunt )0O
o ?ard signs H go to OR" a!arini;e if !ossi.le
o Angiogram indications in e/tremity traumaC
Significant .lunt in4ury wit
`Ldislocation AN# signs of iscemia
A32 R)
Multi!le !enetrating wounds
'&)00E
o Angio is %2,%8O accurate" most errors involve false !ositive
o Always ave glo.al a!!roac to trauma
rLo O5?BR vascular in4ury
rLo oter NON,vascular in4ury
assess neurologic and antici!ated 6UNC52ONAA status of
e/tremity
i&e& mangled e/tremity cec:&
?ard signsC
Any of G 7'8
o 'ain
o 'allor
o 'ulseless
o 'arestesia
o 'oi:ilotermia
o !aralysis
Ongoing .leed
o B/ternal
o 2nternalC
'ulsatile ematoma
3ruits and trill
o AV6
Soft signsC
o #istal !ulse deficit
o A32 R )
o 'resence of soft signs of arterial in4ury
!ro/imity to ma4or vessels
age 2G0
small non,!ulsatile non,e/!anding ematoma
Lo !reos!ital .leedLsoc:
!eri!eral nerve deficit
fracture dislocation
Minimal in line intimal angio in4ury H

intimal fla!"segmental narrowing" ?# insig AV6L!seudoaneurysms H eal witout
surgery
can .e serially o.served wit du!le/Langio&
Non essential vesselsLaneurysms can .e em.oli;ed&
noteC for !ro/imity to ma4or vessel in4ury" most would do serial A32 only" no angio&
Occult in4uryC
2f cose to o.serve" must .e a.le to follow wit !ysical e/am and du!le/& Missed in4ury
seen in only 2,EO of cases 0Osler1
'osterior :nee dislocationC
Reduce first
Cec: iscemiaL!ulses
B/!lore if no !ulse after reduction or iscemia
2f A32 is reduced .ut no iscemia H angiogram ,Q fi/ only ma4or !ro.lems&
326.&rau!atic A-1:
2atrogenic 0!ost !rocedure1
Non,iatrogenic 0true trauma1
2f central in origin" unli:ely to close" so will re>uire re!air&
2f !eri!eral and is NO5 associated wit true trauma 0i&e& iatrogenic origin !ost needle
stic:1" %0O will close in F monts 0average lengt of closure is 28 days1&
2ndication for re!airC
6luid overload
o Venous ?5N
o C?6
#istal iscemia
Non,com!liant !atient
Central locationLnec:
'ost trauma 0as o!!osed to !rocedure1
Keneral recommendation is to wait F monts unless tere are indications 0a.ove1& Re!air
failures& 'ro/imal and distal control& B/!ect ma4or .lood loss&
age 2G)
2f in mid S6A H consider sort covered stentM May try US guided occlusion&
age 2G2
age 2GE

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Canadian Vascular Surgery Minimum

Canadian Vascular Surgery Minimum

176.Co!plications after infrainguinal re*asculari>ation:

o te goal is to decrease te tem!erature and decrease meta.olism" 5?US

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