Transcript ABSITE REVIEW Vascular & Orthopedics

ABSITE REVIEW
Vascular
Jessica O’Connell, MD
January 25, 2012
Q0
Question: Most common cranial nerve injured during CEA?
Vagus nerve (hoarseness)
Question: Other cranial nerves injured during CEA?
Hypoglossal nerve
– tongue deviation toward side of injury
– swallowing/mastication/speech difficulty
Question: What happens if you cut the Ansa Cervicalis
– no serious deficits
– innervates strap muscles
P1
Carotid-body tumor
• Blood supply from ECA
• “splaying of carotid bifurcation (lyre sign)”
• A 58-year-old man has multiple sores on his right lower leg, as shown. He Q3
is diabetic and hypertensive. He can only walk 1 block before becoming
dyspneic. He first noted the sores about 2 months ago.
• On physical examination he has an ulceration measuring 3 x 5 cm on the
anteromedial aspect of his right lower leg above the medial malleolus. The
surrounding skin is brawny with hemosiderin deposition. Similar skin
changes are noted on the anteromedial aspect of the left lower leg. He has
palpable dorsalis pedis pulses bilaterally.
• The most effective nonoperative therapy for this patient would be
A.
B.
C.
D.
E.
elastic compression stockings (Jobst)
paste gauze (Unna) boot
polyurethane foam dressings
hydrocolloid dressings (DuoDerm)
intermittent pneumatic compression
• A 58-year-old man has multiple sores on his right lower leg, as shown. He Q3
is diabetic and hypertensive. He can only walk 1 block before becoming
dyspneic. He first noted the sores about 2 months ago.
• On physical examination he has an ulceration measuring 3 x 5 cm on the
anteromedial aspect of his right lower leg above the medial malleolus. The
surrounding skin is brawny with hemosiderin deposition. Similar skin
changes are noted on the anteromedial aspect of the left lower leg. He has
palpable dorsalis pedis pulses bilaterally.
• The most effective nonoperative therapy for this patient would be
A.
B.
C.
D.
E.
elastic compression stockings (Jobst)
paste gauze (Unna) boot
polyurethane foam dressings
hydrocolloid dressings (DuoDerm)
intermittent pneumatic compression
Q3
• venous stasis ulcers
• trial of nonoperative therapy is indicated in this highrisk surgical patient
• Compressive therapy
• paste gauze (Unna) boots are superior to elastic
compression stockings (Jobst), polyurethane foam
dressings, and elastic compression wraps, hydrocolloid
(DuoDerm)
• combination of intermittent pneumatic compression
(IPC) stockings and elastic compression wraps superior
to elastic compression
• However, the IPC patients also had periods of leg
elevation, which may have influenced the healing rates
• IPC stockings alone have not been compared with
Unna boots
Q38
• Please view the image,
then select the best
answer.
• An arteriovenous fistula (AVF)
that usually requires
transposition
(superficialization) of the
venous outflow
• AVF that has patency rate
equivalent to the BresciaCimino fistula
• Both
• Neither
Q38
• Please view the image,
then select the best
answer.
• An arteriovenous fistula (AVF)
that usually requires
transposition
(superficialization) of the
venous outflow
• AVF that has patency rate
equivalent to the BresciaCimino fistula
• Both
• Neither
Q39
• Please view the image,
then select the best
answer.
• An arteriovenous fistula (AVF)
that usually requires
transposition
(superficialization) of the
venous outflow
• AVF that has patency rate
equivalent to the BresciaCimino fistula
• Both
• Neither
Q39
• Please view the image,
then select the best
answer.
• An arteriovenous fistula (AVF)
that usually requires
transposition
(superficialization) of the
venous outflow
• AVF that has patency rate
equivalent to the BresciaCimino fistula
• Both
• Neither
Q40
• Please view the image,
then select the best
answer.
• An arteriovenous fistula (AVF)
that usually requires
transposition
(superficialization) of the
venous outflow
• AVF that has patency rate
equivalent to the BresciaCimino fistula
• Both
• Neither
Q40
• Please view the image,
then select the best
answer.
• An arteriovenous fistula (AVF)
that usually requires
transposition
(superficialization) of the
venous outflow
• AVF that has patency rate
equivalent to the BresciaCimino fistula
• Both
• Neither
• 38 is the normal anatomy of the right antecubital
fossa
• 39 is the brachial artery to cephalic vein fistula,
probably the most commonly used
• 40 is brachial artery to basilic vein fistula
• In a study comparing the three types of fistulas, all
had patency rates comparable to the forearm
radiocephalic fistula
• the brachial artery to basilic vein required
transposition of the outflow vein (the brachial vein)
into the subcutaneous position
Q38
-40
Q1
Q1
Q1
Q1
• A 53-year-old man has a 1-week history of a painful blue right first Q4
toe. Before his toe turned blue, he was able to climb 4 flights of
stairs without difficulty. On physical examination, his first toe is
bluish, and he has palpable pedal pulses bilaterally. He complains of
numbness and tingling below the knee. He also has a palpable
pulsatile mass in his right popliteal fossa. Ultrasound examination
confirms the presence of a 4-cm right popliteal aneurysm.
A.
B.
C.
D.
E.
F.
The most appropriate treatment would be
systemic anticoagulation
ligation of the aneurysm with bypass graft
endovascular stent
operative resection of the aneurysm with primary repair
aneurysmorrhaphy with interposition graft
• A 53-year-old man has a 1-week history of a painful blue right first Q4
toe. Before his toe turned blue, he was able to climb 4 flights of
stairs without difficulty. On physical examination, his first toe is
bluish, and he has palpable pedal pulses bilaterally. He complains of
numbness and tingling below the knee. He also has a palpable
pulsatile mass in his right popliteal fossa. Ultrasound examination
confirms the presence of a 4-cm right popliteal aneurysm.
A.
B.
C.
D.
E.
F.
The most appropriate treatment would be
systemic anticoagulation
ligation of the aneurysm with bypass graft
endovascular stent
operative resection of the aneurysm with primary repair
aneurysmorrhaphy with interposition graft
• thromboembolic complication from a large popliteal aneurysm
• A combined review of 536 asymptomatic patients with popliteal
aneurysm, with a mean follow-up of approximately 4 years, 35%
developed thromboembolic complications. The associated
amputation rate was 25%.
• Most complications occur in aneurysms with diameters > 2 cm
• early operation for asymptomatic aneurysms larger than 2 cm is
indicated.
• Surgical techniques
– exclusion of the aneurysm with a bypass graft. The aneurysm is ligated
proximally and distally, then continuity is re-established using an extraaneurysmal bypass graft
– Aneurysmorhapy with interposition graft, the aneurysm can be
incised, followed by ligation of any collateral vessels, and then the
bypass graft is placed within the bed of the aneurysm
• indicated for larger aneurysms causing any compressive symptoms - lower leg
pain, numbness, paresthesia, venous congestion, and edema.
• eliminates the possibility of recurrence or continued expansion of the
aneurysm.
– Vascular stent-graft - stents at the knee in a younger person with a low
operative risk ?? durability and long-term patency still under question
Q4
Q5
• A 28-year-old female body builder has the acute onset of a
swollen right arm. Which of the following statements
about her condition is TRUE?
A.
B.
C.
D.
E.
Higher incidence in females
Often accompanied by neurologic symptoms
Not successfully treated with anticoagulation therapy
Definitively treated with catheter-directed thrombolysis
Associated with venous gangrene of the upper
extremities
Q5
• A 28-year-old female body builder has the acute onset of a
swollen right arm. Which of the following statements
about her condition is TRUE?
A.
B.
C.
D.
E.
Higher incidence in females
Often accompanied by neurologic symptoms
Not successfully treated with anticoagulation therapy
Definitively treated with catheter-directed thrombolysis
Associated with venous gangrene of the upper
extremities
•
•
•
•
•
•
•
•
•
•
•
primary axillary-subclavian vein thrombosis
young patients, 2:1 male:female ratio
strenuous or repetitive upper extremity activity
compression of the subclavian vein at the thoracic outlet
often becomes chronic, debilitating venous outflow
obstruction
Neurologic symptoms do not usually accompany primary
venous thrombosis, because the vein and nerves are at the
opposite ends of the thoracic outlet.
traditional treatment elevation of upper
extremity/anticoagulation
persistent symptoms in up to 80%
catheter-directed
followed by dynamic venography
operative thoracic outlet decompression
Q5
Thoracic Outlet
• Subclavian vein
– Passes over 1st rib
– Anterior to anterior scalene m.
– Behind clavicle
•
Brachial plexus & Subclavian
artery
– Pass over 1st rib
– Posterior to anterior scalene m.
– Anterior to middle scalene m
Q5
Thoracic Outlet Exam
Q5
Adson maneuvers: While the patient is in a sitting position, ask the patient to inspire
deeply, hold his breath, and extend his neck. Then, turn the patient's head passively as
far as possible toward one side and then the other. When the head is turned toward the
unaffected side, or sometimes the affected side, obliteration of the radial pulse with a
drop in blood pressure in the arm is considered a positive result.
Roos maneuver: When in the surrender posture, the patient reports paresthesia and
numbness in extremities within 1 minute. This maneuver usually provokes symptoms in
lateral cord distribution.
Elevated-arm stress test: In this test, the patient keeps arms abducted with flexed
elbows for 3 minutes while flexing and extending the fingers. Results are considered
positive if the patient cannot do this for 3 minutes.
Wright maneuver: This maneuver requires the patient to hold the arms next to the
ears. Paresthesias usually are noted down the medial scapular border and into lower
trunk distribution.
Hyperabduction test: The radial pulse is diminished after elevating the involved arm
above the head.
Military maneuver (ie, costoclavicular bracing): This maneuver provokes symptoms
when the patient elevates the chin and pulls the shoulder joint behind in an extreme
"attention" position.
Q1
Question: Which nerve/artery is commonly injured with fracture of
the mid-shaft humerus?
Radial nerve
Question: Which nerve/artery is commonly injured with
supracondylar fracture of the humerus?
Brachial artery
Question: Which nerve/artery is commonly injured with distal
radius fracture?
Median nerve
• A 44-year-old man with diabetes mellitus complicated by peripheral Q6
neuropathy presents with malaise, leukocytosis, and hyperglycemia. He
has received 1 week of antibiotic therapy. The plantar surface of the
foot is pictured.
• Which of the following statements about management of this problem
is TRUE?
A.
B.
C.
D.
E.
Fever is a reliable indicator of the severity of infection
Antimicrobial therapy alone will resolve 50% of cases
Swab cultures of purulent drainage are adequate
Magnetic resonance imaging (MRI) will not reliably diagnose
osteomyelitis in this patient
Immediate transmetatarsal amputation is required
• A 44-year-old man with diabetes mellitus complicated by peripheral Q6
neuropathy presents with malaise, leukocytosis, and hyperglycemia. He
has received 1 week of antibiotic therapy. The plantar surface of the
foot is pictured.
• Which of the following statements about management of this problem
is TRUE?
A.
B.
C.
D.
E.
Fever is a reliable indicator of the severity of infection
Antimicrobial therapy alone will resolve 50% of cases
Swab cultures of purulent drainage are adequate
Magnetic resonance imaging (MRI) will not reliably diagnose
osteomyelitis in this patient
Immediate transmetatarsal amputation is required
Q6
• Foot ulcers occur in 15% of all patients with diabetes
• chronic immunosuppression that accompanies diabetes mellitus, the usual
physical signs and symptoms of infection are often not present
• Diabetic foot wounds must first be probed
–
–
–
–
–
underlying sinus tracts or abscesses
deep or proximal extension along fascial planes
bones and joints involvement
Probing to bone PPV 89% for osteomyelitis in diabetic foot infections
frequently neuropathic patients.
• mixed infections - broad-spectrum antibiotisc
– Staphylococcus aureus, Streptococcus, Enterobacter, and Bacteroides fragilis
• MRI sensitive and specific indicator of true bone marrow infection
– previous trauma, operation, or Charcot osteoarthropathy reduces the
specificity
– combining bone scintigraphy with leukocyte scans - specificity >80%.
• Management
–
–
–
–
avoidance of weightbearing
immediate drainage and debridement procedures
hyperglycemic control
management of ischemia
Q8
• A 56-year-old diabetic man with a history of transmetatarsal amputation
presents with fever, chills, fatigue, malaise, leukocytosis, and
hyperglycemia. His transmetatarsal amputation site is pictured. The
dorsalis pedis and posterior tibial pulses are absent.
Proper management of this condition would be broad-spectrum antibiotics
and
A.
B.
C.
revision of transmetatarsal amputation
immediate surgical debridement of soft tissue only
immediate surgical debridement, and vascular reconstruction of pedal
blood flow
D. immediate surgical debridement, with negative pressure dressing to
improve blood flow
E. immediate below-knee amputation
Q8
• A 56-year-old diabetic man with a history of transmetatarsal amputation
presents with fever, chills, fatigue, malaise, leukocytosis, and
hyperglycemia. His transmetatarsal amputation site is pictured. The
dorsalis pedis and posterior tibial pulses are absent.
Proper management of this condition would be broad-spectrum antibiotics
and
A.
B.
C.
revision of transmetatarsal amputation
immediate surgical debridement of soft tissue only
immediate surgical debridement, and vascular reconstruction of pedal
blood flow
D. immediate surgical debridement, with negative pressure dressing to
improve blood flow
E. immediate below-knee amputation
Q8
• clinically infected, gangrenous transmetatarsal
amputation
• systemic signs and symptoms of sepsis, including
leukocytosis and hyperglycemia
• absence of dorsalis pedis and posterior tibial pulses
• immediate need halt the spread of sepsis before fatal
• immediate broad-spectrum antibiotic therapy
• immediate guillotine amputation
• once the sepsis is controlled, revision of the amputation
can be undertaken
• negative pressure dressings do not improve blood flow to
ischemic tissues
P2
DeBakey Classification
Aortic Dissection
Q9
• Which of the following statements about antithrombotic
treatments is TRUE?
A. In the absence of antithrombin III, unfractionated heparin has
no significant anticoagulant effect
B. Low molecular weight heparins share the ability to accelerate
the activity of factor Xa
C. Warfarin inhibits the absorption of vitamin K from the
intestinal tract
D. Hirudin, a synthetic thrombin inhibitor, is dependent on
antithrombin III for anticoagulant activity
E. The addition of aspirin to heparin increases the anticoagulant
effect without increasing the risk of hemorrhagic side effects
Q9
• Which of the following statements about antithrombotic
treatments is TRUE?
A. In the absence of antithrombin III, unfractionated heparin
has no significant anticoagulant effect
B. Low molecular weight heparins share the ability to accelerate
the activity of factor Xa
C. Warfarin inhibits the absorption of vitamin K from the
intestinal tract
D. Hirudin, a synthetic thrombin inhibitor, is dependent on
antithrombin III for anticoagulant activity
E. The addition of aspirin to heparin increases the anticoagulant
effect without increasing the risk of hemorrhagic side effects
• Unfractionated heparin - indirect thrombin inhibitor
– acceleration of the interaction of antithrombin III with
thrombin (factor IIa)
– In the absence of antithrombin, unfractionated heparin
has no significant antithrombotic effect
– Antithrombin III levels can be increased by the infusion of
fresh frozen plasma
• low molecular weight heparins - inhibition of factor Xa
– down-regulation of thrombin production
• Warfarin - inhibits vitamin K-dependent terminal
carboxylation of factors II, VII, IX, and X in the liver
– oral anticoagulant, no impact on GI absorption of vitamin K
• Hirudin - direct thrombin inhibitor
– isolated from the saliva of the medical leech, reproduced
with recombinant technology
– not dependent on the activity of antithrombin III
– heparin-associated antibodies
Q9
Q10
• Which of the following statements about management of abdominal
aortic aneurysm (AAA) is TRUE?
A.
Elective operation should be considered for patients with symptomatic
AAA in the absence of significant co-morbidities
B. The risk of rupture is higher in women than men for small aneurysms
C. In an otherwise healthy 75-year-old man, a 4.5-cm aneurysm should
be repaired
D. An unreliable patient who is unlikely to comply with lifelong
surveillance should be preferentially offered endograft versus open
repair
E. Mortality is not related to the hospital's volume of AAA repairs
performed
Q10
• Which of the following statements about management of abdominal
aortic aneurysm (AAA) is TRUE?
A.
Elective operation should be considered for patients with symptomatic
AAA in the absence of significant co-morbidities
B. The risk of rupture is higher in women than men for small aneurysms
C. In an otherwise healthy 75-year-old man, a 4.5-cm aneurysm should
be repaired
D. An unreliable patient who is unlikely to comply with lifelong
surveillance should be preferentially offered endograft versus open
repair
E. Mortality is not related to the hospital's volume of AAA repairs
performed
• The mortality of untreated rupture of abdominal aortic aneurysms Q10
(AAA) approaches 100%
• AAA presenting with abdominal and/or back pain (most common)
should be repaired urgently in almost all patients regardless of comorbidity
• UK Small Aneurysm Trial
– significantly higher risk of rupture for small aneurysms in women
compared with men
• Patients undergoing endograft repair of AAA must be willing to
comply with rigorous lifelong surveillance
– graft migration, endoleak, and limb obstruction
• annual risk of rupture 4.5-cm AAA in a 75-year-old man is ~1% per
year - VA-sponsored Aneurysm Detection and Management
(ADAM) trial
• No survival advantage for open repair of small (4.0 to 5.5 cm) AAA
in two large trials in both the United States (ADAM) and Great
Britain (UK Small Aneurysm Trial)
• The average life expectancy for an 80-year-old man after successful
repair of AAA is approximately 7 years, or about half the life
expectancy for an age-matched man without AAA repair
• Mortality is lower with higher hospital volume
Q2
Question: Which nerve/artery is commonly injured with supracondylar
fracture of femur?
Popliteal artery
Question: Which nerve/artery is commonly injured with posterior
dislocation of hip?
Sciatic nerve
Question: Which nerve/artery is commonly injured with posterior
dislocation of knee?
Popliteal artery
Q12
• Which of the following statements about the natural history of
intermittent claudication is TRUE?
A. Five-year survival is > 90%
B. Most patients eventually require revascularization to avoid
amputation
C. One in 4 patients will eventually undergo major amputation
D. Intermittent claudication is a risk factor for adverse
cardiovascular events
E. Abstinence from tobacco does not improve the symptoms of
intermittent claudication
Q12
• Which of the following statements about the natural history of
intermittent claudication is TRUE?
A. Five-year survival is > 90%
B. Most patients eventually require revascularization to avoid
amputation
C. One in 4 patients will eventually undergo major amputation
D. Intermittent claudication is a risk factor for adverse
cardiovascular events
E. Abstinence from tobacco does not improve the symptoms of
intermittent claudication
•
•
•
•
•
•
•
Q12
claudication derived from the root word "to limp“
reproducible leg pain relieved with rest
ankle:brachial index (ABI) -ratio of ankle pressure to arm pressure
normal 0.9 to 1.2
Peripheral arterial disease, ABI < 0.9
25% of elderly patients seen in primary care (1/2 asymptomatic)
Intermittent claudication is relatively benign
– amputation (5% to 7%)
– 25% of patients need intervention
• marker for patients at risk of future adverse cardiovascular events
• modifying the risk factors of systemic atherosclerosis:
– smoking, obesity, hypertension, diabetes, and hyperlipidemia
• The 5-year mortality 30% to 50%, due to cardiovascular events
• Smoking cessation improves the symptoms
Ankle : Brachial index (ABI)
– ratio of ankle pressure to arm pressure
– Ankle : Arm Index (AAI)
•
•
•
•
•
•
•
normal 0.9 to 1.2
Peripheral arterial disease, ABI < 0.9
Claudication 0.4–0.9
Rest pain 0.2–0.5
Tissue loss < 0.4
Gangrene < 0.3
> 0.50 in 85% of patients with single level of
disease
• < 0.50 in 95% with two or more levels of disease
Q12
Q13
• A 30-year-old man presents with a brief history of crampy,
midabdominal pain. Physical examination is notable for diffuse mild
tenderness, but frank signs of peritonitis are absent. Computed
tomographic (CT) scan suggests findings consistent with mesenteric
venous thrombosis.
The initial recommended treatment for symptomatic mesenteric venous
thrombosis is
A.
B.
C.
D.
E.
venous thrombectomy
anticoagulation with heparin
tissue plasminogen activator (tPA) via the superior mesenteric artery
warfarin (Coumadin) anticoagulation
systemic tPA
Q13
• A 30-year-old man presents with a brief history of crampy,
midabdominal pain. Physical examination is notable for diffuse mild
tenderness, but frank signs of peritonitis are absent. Computed
tomographic (CT) scan suggests findings consistent with mesenteric
venous thrombosis.
The initial recommended treatment for symptomatic mesenteric venous
thrombosis is
A.
B.
C.
D.
E.
venous thrombectomy
anticoagulation with heparin
tissue plasminogen activator (tPA) via the superior mesenteric artery
warfarin (Coumadin) anticoagulation
systemic tPA
Q13
• diagnosis of mesenteric venous thrombosis increasing
frequency – CT imaging
• hypercoagulable w/u recommended
• Long-term anticoagulation in asymptomatic patients NOT
generally recommended
• symptomatic patient, treatment is clearly indicated
• thrombolytic agents has not definitively demonstrated to
accelerate the lysis of mesenteric venous thrombosis or
improve the clinical outcome
• Systemic anticoagulation with intravenous heparin and fluid
resuscitation are the mainstays of therapy
• Surgical exploration - signs of abdominal catastrophe
• The apparent lethality of mesenteric venous thrombosis
has decreased during the last decade due to earlier
detection and treatment
• Mesenteric venous thrombosis <10% of clinically significant
mesenteric ischemia
• A hypercoagulable state > 90% of patients
Q14
• A 75-year-old man with a ruptured abdominal aortic aneurysm,
as shown, is taken urgently to the operating room for repair
Which of the following has the most important influence on
operative mortality?
A.
B.
C.
D.
E.
Distance from patient's home to hospital
Number of co-morbidities
Surgeon experience
Annual hospital volume of aneurysm repair
Site of aortic rupture
Q14
• A 75-year-old man with a ruptured abdominal aortic aneurysm,
as shown, is taken urgently to the operating room for repair
Which of the following has the most important influence on
operative mortality?
A.
B.
C.
D.
E.
Distance from patient's home to hospital
Number of co-morbidities
Surgeon experience
Annual hospital volume of aneurysm repair
Site of aortic rupture
• Ruptured abdominal aortic aneurysms (AAA) overall mortality Q14
rate of 90%
• operative mortality arrive at the hospital alive ~50%
• but a number of factors influence the 30-day mortality
• population studies: advanced patient significantly associated
with mortality; however, race, distance from home to
hospital, and medical complexity were not significant factors
• surgeon experience > 10 ruptured AAA had a significantly
lower mortality rate
• annual volume of elective AAA repairs did not influence
outcome, nor did hospital volume of ruptured or elective AAA
repair
Q15
• A 78-year-old man who has the arteriogram shown is being evaluated
for endovascular repair of a 6.5-cm aortic aneurysm. To deploy the
endograft safely, the left limb of the graft must be extended directly into
the left external iliac artery. To prevent an endoleak, the left hypogastric
artery should be occluded using coil embolization.
The most likely adverse event associated with occlusion of the left
hypogastric artery is
A.
B.
C.
D.
E.
buttock claudication
buttock necrosis
spinal cord ischemia
ischemic colitis
impotence
Q15
• A 78-year-old man who has the arteriogram shown is being evaluated
for endovascular repair of a 6.5-cm aortic aneurysm. To deploy the
endograft safely, the left limb of the graft must be extended directly into
the left external iliac artery. To prevent an endoleak, the left hypogastric
artery should be occluded using coil embolization.
The most likely adverse event associated with occlusion of the left
hypogastric artery is
A.
B.
C.
D.
E.
buttock claudication
buttock necrosis
spinal cord ischemia
ischemic colitis
impotence
Q15
• Endovascular aortic aneurysm repair (EVAR) has become a standard
treatment option for aortoiliac aneurysms
• As devices have improved, challenging vascular anatomy short aneurysm
necks and small iliac arteries
• Successful treatment - graft device creates a seal proximal and distal ends
• distal end (landing zone) problem with common iliac aneurysms that
extend to the bifurcation - type I endoleak
• pelvic ischemia a concern if internal iliac artery occluded
• increasing experience - interruption of a single internal iliac artery usually
well tolerated
• coil occlusion or occluding device in internal iliac artery, ipsilateral graft
limb into external iliac artery beyond the bifurcation
• Most patients completely asymptomatic, but 25% to 30% temporary
ipsilateral buttock claudication
• Persistent buttock claudication 10% to 15%
• Buttock necrosis, ischemic colitis, spinal cord ischemia, and impotence
have all been reported, but are rare complications
• bilateral internal iliac artery occlusion has been reported to be well
tolerated in some patients, most recommend maintaining flow in at least
one internal iliac artery
– Internal iliac bypass
– Snorkel technique??
Endovascular Repair of an Abdominal Aortic Aneurysm, with the Use of an Endograft
Greenhalgh R and Powell J. N Engl J Med 2008;358:494-501
The 5 Types of Leakage of Blood into the Aneurysm, or Endoleak
The Four Types of Leakage of Blood into the Aneurysm, or Endoleak
Greenhalgh R and Powell J. N Engl J Med 2008;358:494-501
Q16
• Two days after placement of a brachiocephalic fistula for
hemodialysis access, a 53-year-old man has extensive edema of
the ipsilateral extremity from the hand to the shoulder.
Venography confirms a stenosis in the proximal subclavian vein
creating an 85% diameter loss.
• The best management would be
A.
B.
C.
D.
E.
chronic oral anticoagulation
fistula ligation
fistula banding near the arterial anastomosis
balloon angioplasty of the subclavian vein stenosis
subclavian-jugular venous bypass
Q16
• Two days after placement of a brachiocephalic fistula for
hemodialysis access, a 53-year-old man has extensive edema of
the ipsilateral extremity from the hand to the shoulder.
Venography confirms a stenosis in the proximal subclavian vein
creating an 85% diameter loss.
• The best management would be
A.
B.
C.
D.
E.
chronic oral anticoagulation
fistula ligation
fistula banding near the arterial anastomosis
balloon angioplasty of the subclavian vein stenosis
subclavian-jugular venous bypass
• Pain and swelling in extremity after placement of an arteriovenous access Q16
is indicative of venous hypertension
• hemodynamically significant stenosis in the central venous system, usually
due to previous central venous catheterization
• subclavian vein, innominate vein, axillary vein, and superior vena cava
• Long-term oral anticoagulation will not result in symptomatic
improvement
• ligating the fistula, but sacrifices a functioning access
• External banding will reduce flow in the fistula, but continued venous
hypertension is likely
• Correction of the venous hypertension requires treatment of the central
vein stenosis
• endovascular options may be a reasonable alternative, balloon angioplasty
of central vein stenoses is associated with early recurrence in most cases
– Multiple procedures are often required
– long-term relief <1/3 patients
• Open surgical techniques such as subclavian-jugular bypass or jugular
turndown (jugular subclavian vein transposition) better option, especially
in younger patients with reasonable long-term prognosis
• Although more invasive, long-term patency and symptomatic relief are
better than with angioplasty
Q17
• A 78-year-old woman with chronic atrial fibrillation is admitted with a 2hour history of severe midepigastric abdominal pain that began
suddenly. Her abdomen is nontender on physical examination. An
abdominal computed tomographic (CT) scan obtained in the emergency
department is shown.
• The next step in management should be
A.
B.
C.
D.
mesenteric arteriogram
biliary excretion, eg, HIDA, scan
systemic urokinase
anticoagulation and
serial examination
A. exploratory laparotomy
Q17
• A 78-year-old woman with chronic atrial fibrillation is admitted with a 2hour history of severe midepigastric abdominal pain that began
suddenly. Her abdomen is nontender on physical examination. An
abdominal computed tomographic (CT) scan obtained in the emergency
department is shown.
• The next step in management should be
A.
B.
C.
D.
mesenteric arteriogram
biliary excretion, eg, HIDA, scan
systemic urokinase
anticoagulation and
serial examination
A. exploratory laparotomy
Q17
• Acute mesenteric ischemia sudden onset of severe,
unrelenting abdominal pain
• In the early stages, abdominal examination is relatively
benign
• nonspecific diagnostic findings usually result in delay in
• Embolic occlusion 25% of all cases - nearly all cardiogenic Atrial fibrillation
• Acute mesenteric insufficiency - in situ thrombosis of a preexisting stenosis in the superior mesenteric artery (SMA) in
65%
• Nonocclusive mesenteric ischemia 10%
• arteriography and computed tomography (CT)
• exploratory laparotomy without delay
• time to re-establishing SMA flow is the most important
• peritonitis associated with high mortality rate
• Lytic therapy may be used to buy time if operation is
delayed, delivered through a catheter in SMA
Q18
• Five days after an uncomplicated right carotid endarterectomy,
a 69-year-old man arrives in the emergency department after
the sudden onset of a severe right-sided headache. He is
hemodynamically normal and neurologically intact.
• The next step in management should be
A.
B.
C.
D.
E.
administration of intravenous heparin
carotid duplex ultrasonography
cerebral imaging study
carotid arteriogram
immediate transport to the operating room for carotid reexploration
Q18
• Five days after an uncomplicated right carotid endarterectomy,
a 69-year-old man arrives in the emergency department after
the sudden onset of a severe right-sided headache. He is
hemodynamically normal and neurologically intact.
• The next step in management should be
A.
B.
C.
D.
E.
administration of intravenous heparin
carotid duplex ultrasonography
cerebral imaging study
carotid arteriogram
immediate transport to the operating room for carotid reexploration
Q18
• Hyperperfusion syndrome of the brain - rare but potentially dangerous
complication of carotid endarterectomy (CEA) or carotid artery stenting
• often heralded by severe ipsilateral headache
• progress to seizure activity and cerebral hemorrhage
• prevalence after CEA 0.4% to 7.7%, depending on the definitions used
• Hyperperfusion is believed to represent increased cerebral blood flow in a
territory with disturbed autoregulation
• Proposed risk factors
– correction of a very high grade carotid stenosis (especially when the
contralateral carotid artery is occluded)
– previous stroke
– poor collateral blood supply
– uncontrolled hypertension
• suspected in any patient with severe ipsilateral headache after CEA/CAS
• Imaging to evaluate edema or hemorrhage
– CT – hemorrhage
– MRI with gadolinium enhancement particularly sensitive for subtle changes
associated with hyperperfusion
• risk of cerebral hemorrhage, anticoagulants should not be administered,
antiplatelet agents should be stopped
• Hypertension should be carefully controlled
Q19
• Compared with open repair, endovascular repair of a
6.5-cm infrarenal abdominal aortic aneurysm is
associated with
A.
B.
C.
D.
E.
reduced 30-day morbidity and mortality
longer recovery times due to persistent endoleaks
lower incidence of colon ischemia
fewer re-interventions
lower treatment costs
Q19
• Compared with open repair, endovascular repair of a
6.5-cm infrarenal abdominal aortic aneurysm is
associated with
A.
B.
C.
D.
E.
reduced 30-day morbidity and mortality
longer recovery times due to persistent endoleaks
lower incidence of colon ischemia
fewer re-interventions
lower treatment costs
• Three randomized studies, the EVAR, DREAM and OVER trials, compared Q19
open versus endovascular repair of AAA
• EVAR significantly lower morbidity and mortality at 30 days compared with
open repair
• EVAR (EVAR & DREAM trials) higher number of re-interventions to treat
graft thromosis or endoleaks
– this did not affect the overall recovery rate, faster in the endograft group
• OVER same # reinterventions (hernias, bowel obstructions, wound
complications)
• Ischemic complications - 700 endovascular aneurysm repairs, the
incidence of colon ischemia was similar to that after open repair. However,
small bowel ischemia occurred much more commonly after endografts,
and this complication was associated with high mortality
• Newer studies show risk of colon ischemia lower with EVAR (4 vs. 1.4%)
• high cost of endografts one of main disadvantages of EVAR
• overall higher cost of EVAR compared with open
• additional costs of ongoing surveillance to detect graft complications add
significantly
EVAR
OVER
DREAM
Q19
DREAM
DREAM (6yr f/u)
Q19
Q20
• A 42-year-old woman presents with a recurrent stasis ulcer on the
medial ankle. Venous duplex ultrasonography demonstrates complete
valvular incompetence of the ipsilateral saphenous vein. The deep
venous system is patent, and the valves are competent at all levels. The
ulcer heals after 6 weeks of compression therapy.
• The best long-term management option is
•
•
•
•
•
continued compression therapy with a fitted stocking
ligation of the saphenofemoral junction and saphenous vein stripping
subfascial ligation of perforating veins
excision of ulcer scar and split-thickness skin graft
axillary vein valve transfer
Q20
• A 42-year-old woman presents with a recurrent stasis ulcer on the
medial ankle. Venous duplex ultrasonography demonstrates complete
valvular incompetence of the ipsilateral saphenous vein. The deep
venous system is patent, and the valves are competent at all levels. The
ulcer heals after 6 weeks of compression therapy.
• The best long-term management option is
•
•
•
•
•
continued compression therapy with a fitted stocking
ligation of the saphenofemoral junction and saphenous vein stripping
subfascial ligation of perforating veins
excision of ulcer scar and split-thickness skin graft
axillary vein valve transfer
Q20
• venous stasis ulcers 1% of the adult population, 1/3
unhealed
• prolonged venous hypertension from valvular insufficiency
in the saphenous venous system, the deep venous system,
or both
• Subfascial ligation - valvular incompetence of the deep or
perforating veins
• Ligation of the saphenofemoral junction has been
associated with ulcer healing, local anesthesia.
• saphenous vein stripping is unnecessary to achieve initial
ulcer healing, long-term recurrence of venous insufficiency
is more likely if the saphenofemoral junction is ligated
without stripping the vein
• Endoluminal saphenous vein ablation using laser or
radiofrequency techniques may be an equally good option,
but long-term results are not yet known
• Transfer of an axillary vein segment containing a competent
valve - deep venous insufficiency
Q21
• A 53-year-old man presents with a 2-day history of pain and
swelling in the left leg and thigh. Magnetic resonance
venography confirms thrombotic occlusion of the left common
and external iliac veins. He is otherwise in good health and has
no contraindications to anticoagulation.
• This patient should receive
A.
B.
C.
D.
E.
unfractionated heparin only
low molecular weight heparin
direct thrombin inhibitor
catheter-directed thrombolysis
systemic thrombolysis
Q21
• A 53-year-old man presents with a 2-day history of pain and
swelling in the left leg and thigh. Magnetic resonance
venography confirms thrombotic occlusion of the left common
and external iliac veins. He is otherwise in good health and has
no contraindications to anticoagulation.
• This patient should receive
A.
B.
C.
D.
E.
unfractionated heparin only
low molecular weight heparin
direct thrombin inhibitor
catheter-directed thrombolysis
systemic thrombolysis
• Conventional therapy DVT systemic heparin followed by oral
anticoagulation for 3 to 6 months
• effective in reducing the risk of pulmonary embolus (PE) and recurrent
DVT
• iliofemoral DVT at risk for postthrombotic syndrome
• incomplete venous recanalization and loss of normal venous valvular
function
• Surgical thrombectomy often incomplete, and early recurrence of the
thrombosis commonplace
Q21
– rarely performed except in highly symptomatic patients due to phlegmasia
• Catheter-directed lytic therapy - introduce the lytic agent directly into the
clot (place retrievable IVC filter)
• fewer bleeding complications compared with systemic lysis
• Multicenter trials overall success rate in over 80% of treated patients, with
a major bleeding rate of 11% and a PE rate of 1%
• New mechanical endovascular devices have improved the speed and
success rate of clot dissolution
• Once thrombus has been cleared, oral anticoagulation 6 months
• health-related quality of life better with lytic therapy - better overall
physical functioning, less health distress, and fewer postthrombotic
symptoms
Q22
• A 32-year-old man presents with chronic left leg pain and edema.
Duplex ultrasonography demonstrates continuous flow in the external
iliac vein that is suggestive of proximal vein obstruction. Venography
demonstrates a stenosis of the left common iliac vein in the area
underlying the right common iliac artery.
• The most appropriate treatment would be
A.
immediate administration of heparin, followed by long-term
anticoagulation
B. systemic administration of a lytic agent
C. catheter-based lytic therapy
D. placement of a self-expanding stent
E. surgical resection of the obstructing lesion
Q22
• A 32-year-old man presents with chronic left leg pain and edema.
Duplex ultrasonography demonstrates continuous flow in the external
iliac vein that is suggestive of proximal vein obstruction. Venography
demonstrates a stenosis of the left common iliac vein in the area
underlying the right common iliac artery.
• The most appropriate treatment would be
A.
immediate administration of heparin, followed by long-term
anticoagulation
B. systemic administration of a lytic agent
C. catheter-based lytic therapy
D. placement of a self-expanding stent
E. surgical resection of the obstructing lesion
• In humans, the left common iliac vein is crossed
anteriorly by the right common iliac artery
• chronic compression of the vein by the artery
Q22
– May-Thurner syndrome
• most cases asymptomatic
• risk factor for deep venous thrombosis (DVT)
• Patients may present with pain and edema due to
venous hypertension before the onset of DVT
• Endovascular therapy with metallic stents is
effective in relieving the external compression,
with 2-year primary patency rates > 90%
• catheter-directed lysis to treat venous thrombosis
before stent placement
Q23
• Endovascular repair of an abdominal aortic
aneurysm has improved outcome over open repair in
all of the following EXCEPT
A.
B.
C.
D.
E.
graft complications
mortality
cardiac complications
pulmonary complications
length of hospital stay
Q23
• Endovascular repair of an abdominal aortic
aneurysm has improved outcome over open repair in
all of the following EXCEPT
A.
B.
C.
D.
E.
graft complications
mortality
cardiac complications
pulmonary complications
length of hospital stay
Q24
• Which of the following statements about arteriovenous fistulas
(AVFs) for hemodialysis access in patients with end-stage renal
disease is TRUE?
A. AVFs should be placed immediately after patients have started
dialysis
B. Over 50% of such patients are being dialyzed through AVFs
C. The radiocephalic fistula can be done in over 50% of all
patients
D. If an AVF fails to mature properly, secondary operations are
rarely successful
E. For a patient with small vessels, a prosthetic graft will provide
a higher patency rate than a radiocephalic fistula
Q24
• Which of the following statements about arteriovenous fistulas
(AVFs) for hemodialysis access in patients with end-stage renal
disease is TRUE?
A. AVFs should be placed immediately after patients have started
dialysis
B. Over 50% of such patients are being dialyzed through AVFs
C. The radiocephalic fistula can be done in over 50% of all
patients
D. If an AVF fails to mature properly, secondary operations are
rarely successful
E. For a patient with small vessels, a prosthetic graft will
provide a higher patency rate than a radiocephalic fistula
Q24
• In any given year, some 240,000 patients with end-stage renal
disease are being treated with maintenance hemodialysis
• Venous catheters last only a few months at most
• arteriovenous grafts may last a year or two
• arteriovenous fistula (AVF) may last for several years, the best
method of access
• Center for Medicare and Medicaid Services (CMS) has announced a
Fistula First movement, with the objective of placing AVFs in dialysis
patients before they begin receiving dialysis. It takes 3 to 4 months
for a fistula to mature, and often longer, especially in diabetics, and
a revision may be necessary
• Achieving a higher rate of first-use AVF requires that patients be
identified 6 to 12 months prior
• The radiocephalic arteriovenous fistula (Brescia-Cimino shunt) best
• More than half of patients cannot have because vessels too small or
because cephalic vein occluded
• forearm loop graft with prosthetic material, which has a lower
patency rate than a Brescia-Cimino shunt, superior in patients with
small vessels
• In prosthetic grafts, just as with nongraft fistulas, re-operation will
often salvage a clotted fistula
Q25
• A 32-year-old man presents with swelling of the forearm, as shown. He
has intermittent tingling in the ring and small fingers. He is in moderate
discomfort. Two-point discrimination is slightly diminished in the ring
and small fingers. Hand compartments are soft. X-rays show soft tissue
swelling and no obvious fracture. Compartment pressures are 20 mm Hg
for the volar forearm compartment, 16 mm Hg for the dorsal
compartment, and 18 mm Hg for the mobile wad.
• The next step should be
A.
B.
C.
D.
E.
analgesics and antibiotics with discharge home
hospital admission, serial examinations
hospital admission, hyperbaric oxygen
carpal tunnel release
volar and dorsal forearm fasciotomy
Q25
• A 32-year-old man presents with swelling of the forearm, as shown. He
has intermittent tingling in the ring and small fingers. He is in moderate
discomfort. Two-point discrimination is slightly diminished in the ring
and small fingers. Hand compartments are soft. X-rays show soft tissue
swelling and no obvious fracture. Compartment pressures are 20 mm Hg
for the volar forearm compartment, 16 mm Hg for the dorsal
compartment, and 18 mm Hg for the mobile wad.
• The next step should be
A.
B.
C.
D.
E.
analgesics and antibiotics with discharge home
hospital admission, serial examinations
hospital admission, hyperbaric oxygen
carpal tunnel release
volar and dorsal forearm fasciotomy
• gunshot wound to the forearm
• risk for compartment syndrome
• may also have injury to the ulnar nerve related to direct injury or
compression from local edema or blast injury
• documentation of presenting and subsequent neurologic examinations
• Sensory deficits (paresthesias or numbness) usually precede motor
dysfunction
• Muscles and nerves are especially vulnerable to ischemia and incur
irreversible damage if increased pressures are maintained
• compartment syndrome (pain out of proportion to the injury, pain with
passive extension of the compartment muscles, swollen tense
compartments)
• confirmed by intracompartmental tissue fluid pressures > 30 mm Hg
• forearm has three major compartments:
– anterior (volar)
– posterior (dorsal)
– mobile wad (includes brachioradialis, extensor carpi radialis longus, and
extensor carpi radialis brevis)
– The carpal canal, although open at both ends, is a physiologic compartment
and should be released when median nerve compression is identified.
• Hyperbaric oxygen is not an acceptable primary treatment for
compartment syndrome
Q25
Q25
Q27
• A 57-year-old man has the
angiogram shown. Which of the
following statements is TRUE?
A. Anticoagulation is indicated
B. Limb loss is likely without
revascularization
C. He is likely to complain of pain in
his foot with walking
D. He has a decreased life expectancy
E. Antiplatelet therapy has no role in
the medical management of this
patient
Q27
• A 57-year-old man has the
angiogram shown. Which of the
following statements is TRUE?
A. Anticoagulation is indicated
B. Limb loss is likely without
revascularization
C. He is likely to complain of pain in
his foot with walking
D. He has a decreased life expectancy
E. Antiplatelet therapy has no role in
the medical management of this
patient
Q27
• occlusion of the superficial femoral artery
• peripheral arterial disease (PAD)
• Claudication - intermittent nature with occurrence during exercise and
abatement with rest
• calf, thigh, and buttock
• Symptoms occur distal to the stenosis or occlusion as oxygen demand
increases with exercise but cannot be supplied
• Foot pain with ambulation is not a typical presentation because the
amount of muscle in the calf is far greater and usually produces symptoms
first
• Anticoagulation will not improve walking distance and is not indicated
• Revascularization is only required in one third of patients with claudication
and limb loss is relatively rare
• More ominous, however, is the association of claudication and peripheral
arterial disease with stroke and myocardial infarction
• Patients with symptomatic peripheral arterial disease have twice the risk
of mortality from these atherothrombotic disease processes
• Antiplatelet agents are indicated in these patients to reduce
cardiovascular mortality and morbidity
Q28
• Which of the following statements about the findings
shown in this computed tomographic (CT) scan is TRUE?
A. This is the most common site of aneurysmal disease
B. Successful surgical repair eliminates any further
enlargement
C. Rupture is more likely to occur than thrombosis
D. Embolization from the aneurysm is a continuous risk
E. There is no role for thrombolytic therapy
Q28
• Which of the following statements about the findings
shown in this computed tomographic (CT) scan is TRUE?
A. This is the most common site of aneurysmal disease
B. Successful surgical repair eliminates any further
enlargement
C. Rupture is more likely to occur than thrombosis
D. Embolization from the aneurysm is a continuous risk
E. There is no role for thrombolytic therapy
•
•
•
•
•
•
•
•
•
•
•
•
•
Q28
aneurysms of both popliteal arteries (the left is larger than the right)
Abdominal aortic aneurysms (AAA) occur more frequently, but aneurysms of the
popliteal artery are the most frequently occurring peripheral arterial aneurysms,
accounting for more than 70%
Unlike AAAs, rupture of an aneurysm in this location is extremely rare
Most patients present with symptoms of emoblization (blue toes) or acute limb
ischemia
Many authors recommend surgical intervention when the aneurysm is diagnosed
The risk of developing symptoms is ~14% per year and includes the risk of
complete thrombosis. Limb loss in this setting occurs in approximately 30%
Planning revascularization is often complicated by the embolization and
thrombosis of normal caliber distal vessels that would have been suitable for
bypass
Thombolytic therapy in this setting to identify patent distal vessels, improve small
vessel flow, and improve subsequent bypass patency
Surgical intervention requires ligation of the aneurysm and reconstruction with
autogenous conduit whenever possible
80% patency at 5 years is commonly reported
endovascular exclusion of the aneurysm with in-line reconstruction with a covered
stent graft
Even with ligation of the proximal and distal vessel around the aneurysm, patency
of the geniculates resulting in continued aneurysm growth has been reported
This complication is best treated with exploration from a posterior incision with
ligation of the patent vessels from within the aneurysm sac
Q29
• Which of the following statements about
the lesion shown is TRUE?
A.
If the patient is otherwise healthy and
asymptomatic, this lesion should be
managed medically
B. The patient is at increased risk of stroke,
heart attack, and death with or without
operative intervention
C. Endovascular treatment is associated with
improved outcome when compared with
operation
D. Successful operative or endovascular
intervention eliminates the need for
continued medical therapy
E. If the patient has already had a stroke,
operative intervention is not indicated
Q29
• Which of the following statements about
the lesion shown is TRUE?
A.
If the patient is otherwise healthy and
asymptomatic, this lesion should be
managed medically
B. The patient is at increased risk of stroke,
heart attack, and death with or without
operative intervention
C. Endovascular treatment is associated with
improved outcome when compared with
operation
D. Successful operative or endovascular
intervention eliminates the need for
continued medical therapy
E. If the patient has already had a stroke,
operative intervention is not indicated
• severe stenosis of the right internal and
external carotid artery
• patients with atherosclerotic disease of the
internal carotid artery are at increased risk of
coronary artery disease, heart attack, stroke,
and death, regardless of the therapy offered
Q29
Q31
• A 75-year-old man who had an abdominal
aortic aneurysm repair 5 years previously with
an aorto-bifemoral graft presents with malaise
and generalized abdominal pain. On physical
examination, his abdomen is diffusely tender
and he is normotensive. Pertinent data include
a hemoglobin of 12 g/dL and WBC count of
19,800/mm3. The computed tomographic (CT)
scan shown is obtained.
• Which of the following statements about his
diagnosis and management is TRUE?
A.
B.
C.
D.
E.
Treatment will require ostomy formation
A negative upper endoscopy eliminates the
need for operation
Graft excision and extra-anatomic
reconstruction should be performed
immediately
Systemic antibiotics should be started
immediately
Percutaneous drainage is adequate therapy
Q31
• A 75-year-old man who had an abdominal
aortic aneurysm repair 5 years previously with
an aorto-bifemoral graft presents with malaise
and generalized abdominal pain. On physical
examination, his abdomen is diffusely tender
and he is normotensive. Pertinent data include
a hemoglobin of 12 g/dL and WBC count of
19,800/mm3. The computed tomographic (CT)
scan shown is obtained.
• Which of the following statements about his
diagnosis and management is TRUE?
A.
B.
C.
D.
E.
Treatment will require ostomy formation
A negative upper endoscopy eliminates the
need for operation
Graft excision and extra-anatomic
reconstruction should be performed
immediately
Systemic antibiotics should be started
immediately
Percutaneous drainage is adequate therapy
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Q31
Prosthetic graft infections most dreaded complicatios after aortic reconstruction, 1% to 6% of cases
generalized malaise, fever, leukocytosis with melena, and hematemesis if the graft has eroded into
the adjacent bowe
CT findings: perigraft air or fluid, soft tissue attenuation between the graft and the aortic wall after
the immediate perioperative period
Aortoenteric fistulas most frequently occur at the site of the proximal anastomosis of the graft to
the aorta and involve the third portion of the duodenum
Upper endoscopy may confirm this diagnosis, but might dislodge an already tenuous clot within the
lumen of the bowel - best performed in the operating room
Small bowel fistulas in this setting may be closed primarily and excluded from the site of aortic
repair with a wrap of omentum or well-vascularized soft tissue
complete graft excision with aggressive retroperitoneal debridement and extra-anatomic
reconstruction has been recommended
Mortality rates remain at 30% in the immediate postoperative period
For normotensive patients who are not actively bleeding, a radionuclide-labeled WBC scan may
provide additional useful information, such as whether the graft in the region of the groins is also
infected
staged procedures - Extra-anatomic bypass may be performed first after appropriate antibiotics
have been administered and the patient's condition has stabilized, followed by laparotomy and
excision of all infected graft material -improved patient survival
survivors remain at risk for aortic stump blowout, thrombosis of the extra-anatomoic bypass, and
amputation of the extremities
Most of these infections develop 5 or more years after initial operation and are from fastidious
organisms such as Staphylococcus epidermidis
low virulence of these organisms has led many to suggest that long-term antibiotics in conjunction
with aggressive debridement with in situ reconstruction may be possible
antibiotic-impregnated grafts, arterial homografts, and autogenous vein grafts harvested from the
patient's own deep femoral system of veins
Q32
• A 65-year-old woman with a long history of
varicose veins has had the ulcer shown,
above her medial malleolus, for several
months.
• Which of the following statements about
her condition is TRUE?
A.
Preoperative evaluation to identify
sources of venous reflux, tributaries, and
vein size will not change management
B. Based on its location, this ulcer is arterial
in etiology
C. This is likely the result of a duplication of
the greater saphenous vein
D. Therapy should be directed at eliminating
venous hypertension
E. Greater saphenous vein stripping will be
required to achieve wound healing
Q32
• A 65-year-old woman with a long history of
varicose veins has had the ulcer shown,
above her medial malleolus, for several
months.
• Which of the following statements about
her condition is TRUE?
A.
Preoperative evaluation to identify
sources of venous reflux, tributaries, and
vein size will not change management
B. Based on its location, this ulcer is arterial
in etiology
C. This is likely the result of a duplication of
the greater saphenous vein
D. Therapy should be directed at
eliminating venous hypertension
E. Greater saphenous vein stripping will be
required to achieve wound healing
Q32
• Conservative measures to reduce venous
hypertension
• compression dressings, such as an Unna boot or
Profore dressing
• rule out deep venous thrombosis
• saphenofemoral junction can be evaluated for the
presence of reflux
• Elimination of the proximal segment and its
tributaries may be all that is required to alleviate
venous hypertension and promote wound healing
• Reflux along the entire length of the greater
saphenous vein remains an indication for
complete excision or ablation
P3
Compartments of the Lower Leg
Compartment
Muscles
Neurovascular structures
Anterior compartment
Tibialis anterior, Extensor
hallucis longus, Extensor
deep peroneal nerve
digitorum longus, Peroneus Anterior Tibial vessels (AT)
tertius
Lateral compartment
Peroneus longus, Peroneus
brevis
Deep posterior
compartment
Tibialis posterior, Flexor
tibial nerve
hallucis longus, Flexor
posterior tibial vessels (PT)
digitorum longus, Popliteus peroneal artery (peroneal)
Superficial posterior
compartment
Gastrocnemius, Soleus,
Plantaris
superficial peroneal nerve
medial sural cutaneous
nerve
Q33
• Which of the following statements about
common iliac artery aneurysms is TRUE?
A.
B.
C.
D.
E.
Surgical repair is not recommended until it is 5 cm
Endovascular repair is not recommended
They are usually infectious in etiology
They frequently rupture when < 3 cm
They are most often associated with other
aneurysms
Q33
• Which of the following statements about
common iliac artery aneurysms is TRUE?
A.
B.
C.
D.
E.
Surgical repair is not recommended until it is 5 cm
Endovascular repair is not recommended
They are usually infectious in etiology
They frequently rupture when < 3 cm
They are most often associated with other
aneurysms
• Isolated common iliac artery aneurysms occur in only 0.1% to 1.9% Q33
of all patients with aneurysmal disease
• atypical causes such as infection, trauma, medial necrosis,
fibrodysplasia, cystic necrosis, Marfan's, or nonspecific
inflammatory conditions
• liac artery aneurysms are found in 10% to 20% of patients with AAA
• difficulty in palpating these aneurysms and their asymptomatic
nature, rupture and mortality rates are high
• one retrospectively reviewed series, no significant rate of expansion
was seen over 4 years in aneurysms < 3 cm, and no deaths were
attributable to aneurysmal disease. Currently, repair is not
recommended for aneurysms < 3 cm
• Endovascular treatment options both in conjunction with AAA
repair individually
• covered stent and endovascular coiling of an internal iliac artery if a
sufficient seal zone of 1.5 cm cannot be obtained proximal to its
origin to decrease flow to the aneurysm sac
• Preservation of the contralateral internal iliac flow and collaterals is
important to preserve flow to the pelvis
Q34
• Development of the lower extremity
postthrombotic syndrome (stasis, edema,
pigmentation, ulceration)
A. is most likely in patients with multi-segment
thrombosis
B. is effectively prevented by a 6-month course of low
molecular-weight heparin
C. occurs in15% to 20% of all patients with deep vein
thrombophlebitis
D. is uncommon after isolated calf vein
thrombophlebitis
E. is due entirely to valvular insufficiency
Q34
• Development of the lower extremity
postthrombotic syndrome (stasis, edema,
pigmentation, ulceration)
A. is most likely in patients with multi-segment
thrombosis
B. is effectively prevented by a 6-month course of low
molecular-weight heparin
C. occurs in15% to 20% of all patients with deep vein
thrombophlebitis
D. is uncommon after isolated calf vein
thrombophlebitis
E. is due entirely to valvular insufficiency
• The postthrombotic syndrome is a highly morbid late Q34
complication of deep vein thrombophlebitis (DVT) of
the lower extremities
• Within 5 years of the sentinel episode, 40% to 60% of
patients will develop clinically significant signs and
symptoms of the syndromechronic leg edema and
pain, dermatitis, and ulceration
• The most common inciting factor is a recurrent episode
of DVT after resolution of the initial insult
• Obesity and inherited coagulopathies also place
patients at greater risk
• valvular damage is permanent and venous reflux
• Permanent obstruction of one or more venous
segments, resulting in outflow obstruction and venous
hypertension
• ineffective calf muscular pump function
Q35
• A 77-year-old woman presents with a cold left
hand. After operative embolectomy, the next
step in this patient's evaluation should be
A. magnetic resonance angiogram of the
subclavian arteries
B. duplex examination of the carotid arteries
C. echocardiogram
D. cardiac catheterization
E. Adson's maneuver
Q35
• A 77-year-old woman presents with a cold left
hand. After operative embolectomy, the next
step in this patient's evaluation should be
A. magnetic resonance angiogram of the
subclavian arteries
B. duplex examination of the carotid arteries
C. echocardiogram
D. cardiac catheterization
E. Adson's maneuver
• Acute extremity ischemia can be caused by either
thrombosis or embolism
• Distinguishing between the two is often difficult
• history of acute onset that can be pinpointed exactly in
time is more consistent with an embolic phenomenon
• Peripheral emboli most commonly arise from the heart
Q35
– valvular heart disease or atrial arrhythmia
• aneurysms of the upper extremity arteries with subsequent
mural thrombus and embolism, embolism from an aortic
plaque, or embolism associated with arterial
instrumentation
• Echocardiography - search for valvular abnormalities,
thrombosis in any of the cardiac chambers, and search for
septal defects
• Magnetic resonance angiography (MRA) of the subclavian
arteries would be indicated if echocardiography is negative,
duplex better initial screening test
Q36
• Three days after knee arthroscopy, a 35-year-old man
presents with mild dyspnea on exertion. His
temperature is 100ºF. His chest is clear to auscultation,
except for right lower lobe rales. Minimal knee swelling
is noted at the arthroscopy site. His WBC count is
12,400/mm3 and D-dimer level is normal. The chest xray shows obscuring of the right hemidiaphragm.
• The next diagnostic test should be
A.
B.
C.
D.
E.
bilateral lower extremity duplex examination
contrast venography
ventilation/perfusion scan
computed tomographic (CT) angiography
sputum culture
Q36
• Three days after knee arthroscopy, a 35-year-old man
presents with mild dyspnea on exertion. His
temperature is 100ºF. His chest is clear to auscultation,
except for right lower lobe rales. Minimal knee swelling
is noted at the arthroscopy site. His WBC count is
12,400/mm3 and D-dimer level is normal. The chest xray shows obscuring of the right hemidiaphragm.
• The next diagnostic test should be
A.
B.
C.
D.
E.
bilateral lower extremity duplex examination
contrast venography
ventilation/perfusion scan
computed tomographic (CT) angiography
sputum culture
Q36
• Whenever a patient presents with respiratory symptoms after an
operation, deep venous thrombosis (DVT) and subsequent pulmonary
embolus must be among the differential diagnoses
• DVT in only 20% to 35%
• diagnostic tests are time-consuming, costly, or have a finite complication
rate
• Serum D-dimer is a rapid and simple screening test that may be used to
eliminate up to 80% of patients without venous thromboembolism (VTE)
• D-dimer is a degradation product of cross-linked fibrin
• Although levels are elevated during any thromboembolic event, many
nonthrombotic events, including operation, may cause transient
elevations in D-dimer
• For this reason, documentation of suspected VTE under such
circumstances requires additional diagnostic work-up
• D-dimer has a negative predictive value of 96% to 100%
• When combined with a low clinical suspicion in a patient with a likely
alternative diagnosis, the negative predictive values approach 98% to 99%
• For this patient with a presumptive diagnosis of pneumonia and a normal
D-dimer level, significant VTE is virtually excluded, making any further
diagnostic test unnecessary
Q37
• Following a routine knee arthroscopy, a healthy
33-year-old man develops an uncomplicated
femoral deep venous thrombosis. A
hypercoagulable evaluation is negative.
Anticoagulation should be given
A.
B.
C.
D.
E.
for 6 weeks
for 3 months
for 1 year
until symptoms resolve
for life
Q37
• Following a routine knee arthroscopy, a healthy
33-year-old man develops an uncomplicated
femoral deep venous thrombosis. A
hypercoagulable evaluation is negative.
Anticoagulation should be given
A.
B.
C.
D.
E.
for 6 weeks
for 3 months
for 1 year
until symptoms resolve
for life
• The optimal duration of oral anticoagulation for an uncomplicated Q37
deep venous thrombosis (DVT) has long been debated
• Traditional teaching 3- to 6-month
• complication rate with warfarin (Coumadin)
• DVT isolated to the calf without proximal extension or pulmonary
embolism, 6 weeks of treatment might be sufficient
• The American College of Chest Physicians Consensus Statement
recommends 3 months of treatment for a first-time DVT episode
with a known transient, reversible risk factor, as in this patient
• Longer periods of treatment (6 months to 1 year) are
recommended for patients with permanent risk factors (obesity,
varicosity, heart failure, immobile status, malignancy, and known
thrombophilia) or idiopathic thrombosis (no known risk factors)
• Many patients in the latter group may have an undiagnosed
hypercoagulable state with estimates ranging from as little as 1% to
as high as 30% of patients presenting with DVT
• A number of thrombophilic conditions have been identified:
Anticardiolipin antibody syndrome, antithrombin III deficiency,
protein C and S levels deficiency, and factor V Leiden are the most
common
Q37
P4
Embolism vs. Thrombosis
Q41
• Nonoperative management is MOST appropriate for
A. a 6-cm pseudoaneurysm of the common femoral
artery after cardiac catheterization
B. intimal flap in the popliteal artery after posterior knee
dislocation that is not flow-limiting
C. pulsatile bleeding from a stab wound to the thigh in a
hemodynamically stable patient
D. large traumatic arteriovenous fistula between the
superficial femoral artery and vein from a low-velocity
gunshot wound
E. cool, pulseless foot after external fixation of a femur
fracture
Q41
• Nonoperative management is MOST appropriate for
A. a 6-cm pseudoaneurysm of the common femoral
artery after cardiac catheterization
B. intimal flap in the popliteal artery after posterior
knee dislocation that is not flow-limiting
C. pulsatile bleeding from a stab wound to the thigh in a
hemodynamically stable patient
D. large traumatic arteriovenous fistula between the
superficial femoral artery and vein from a low-velocity
gunshot wound
E. cool, pulseless foot after external fixation of a femur
fracture
• Increasingly, nonoperative management has been successfully applied to Q41
selected traumatic vascular injuries
• In particular, minor intimal injuries that involve less than 50% of the
arterial diameter and are not flow limiting usually heal spontaneously
(image 1)
• intervention is appropriate for most arterial injuries, including occlusions
resulting in ischemia, persistent hemorrhage, arteriovenous fistula, and
large pseudoaneurysms
• Arterial spasm (image 2) is frequently observed in arteries adjacent to
traumatic soft tissue injuries and typically does not require specific
treatment
1
2
•
•
•
•
•
Most traumatic arteriovenous fistulas (image 3) should be treated either by coil Q41
embolization or surgical ligation because of their tendency to enlarge with time
Arterial occlusion (image 4) usually warrants surgical intervention unless the
patient's overall condition precludes surgical intervention or redundant circulation
to the affected part is believed to be sufficient to eliminate ischemia
Extravasation of contrast (image 5) during angiography indicates ongoing
hemorrhage requiring definitive treatment, either in the form of catheter-based
intervention or surgical repair
While small (< 2 cm) posttraumatic, eg, after cardiac catheterization,
pseudoaneurysms can be safely observed in anticipation of spontaneous
thrombosis, larger pseudoaneurysms require treatment
ultrasound-guided compression, percutaneous thrombin injection, and
conventional surgical repair.
3
4
5
Q41
• Image 6 demonstrates a large
pseudoaneurysm arising from
the profunda femoris artery
after a stab wound to the groin.
One coil has already been
placed
6
Q42
•
•
•
•
A.
B.
C.
D.
E.
A 40-year-old male unrestrained driver is brought to the emergency department
after being ejected from his car during a motor vehicle crash.. Four hours after
injury, he is in class IV hemorrhagic shock with a Glasgow coma scale score of 14.
Core temperature is 34°C, and he has a base deficit of -18. After primary and
secondary survey, his only injury is an isolated severely comminuted open distal
femur fracture
Focused assessment with sonography for trauma (FAST) is negative, but he has
active bleeding from a crush injury to the mid thigh.
The patient is taken to the operating room for ongoing arterial and venous
bleeding from his thigh wound. Despite ongoing massive resuscitation, he remains
in shock and is hypothermic (temperature < 34°C), acidotic (pH < 7.20), and
coagulopathic (INR > 1.5).
The most appropriate choice in management now would be
above-knee amputation of the right lower extremity
angiography of the right lower extremity followed by external fixation of the
right tibia and femur
right below-knee amputation with exploration of the femoral vessels and repair
followed by external fixation of both femurs
immediate ligation of the superficial femoral artery followed by external fixation
of the fractures
application of a tourniquet to the right thigh and delayed vascular reconstruction
Q42
•
•
•
•
A.
B.
C.
D.
E.
A 40-year-old male unrestrained driver is brought to the emergency department
after being ejected from his car during a motor vehicle crash.. Four hours after
injury, he is in class IV hemorrhagic shock with a Glasgow coma scale score of 14.
Core temperature is 34°C, and he has a base deficit of -18. After primary and
secondary survey, his only injury is an isolated severely comminuted open distal
femur fracture
Focused assessment with sonography for trauma (FAST) is negative, but he has
active bleeding from a crush injury to the mid thigh.
The patient is taken to the operating room for ongoing arterial and venous
bleeding from his thigh wound. Despite ongoing massive resuscitation, he remains
in shock and is hypothermic (temperature < 34°C), acidotic (pH < 7.20), and
coagulopathic (INR > 1.5).
The most appropriate choice in management now would be
above-knee amputation of the right lower extremity
angiography of the right lower extremity followed by external fixation of the
right tibia and femur
right below-knee amputation with exploration of the femoral vessels and repair
followed by external fixation of both femurs
immediate ligation of the superficial femoral artery followed by external fixation
of the fractures
application of a tourniquet to the right thigh and delayed vascular reconstruction
• likelihood of achieving a functional limb versus the problems Q42
associated with limb salvage (time involved, duration of
disability, medical risks, socioeconomic costs, number of
operations and hospitalizations, etc)
• The absolute indication for amputation in trauma remains an
ischemic limb with unreconstructable vascular injury in a
patient with hypothermia, metabolic acidosis, and
coagulopathy
• Massively crushed muscle and ischemic tissue can release
myoglobin and cytokines, leading to a systemic inflammatory
response syndrome, resulting in renal failure, adult
respiratory distress syndrome, and even death
• Prolonged attempts at limb salvage, even though technically
possible, may endanger the patient's life and generally should
be avoided
Q42
Foot Amputations
Amputation of any part of the foot. This
includes mid tarsal amputations, Lisfranc
amputation, Boyds amputation, and Symes
amputation
Transtibial Amputations (below the knee)
Amputation occurs at any level from the knee
to the ankle
Knee Disarticulation
Amputation occurs at the level of the knee
joint
Transfemoral Amputations (above knee ):
Amputation occurs at any level from the hip to
knee joint
Hip Disarticulation:
Amputation is at the hip joint with the entire
thigh portion being removed.
P2
Q44
• A 27-year-old woman sustains a blunt carotid
injury. Carotid angiography demonstrates a
carotid dissection beginning in the bulb and
extending to the petrous portion. A small residual
lumen is present.
• The optimal treatment would be
A. carotid artery stent placement
B. systemic anticoagulation with unfractionated
heparin
C. carotid exploration
D. external carotid-internal carotid (ECIC) bypass
E. low molecular weight heparin (30 mg/kg/day)
Q44
• A 27-year-old woman sustains a blunt carotid
injury. Carotid angiography demonstrates a
carotid dissection beginning in the bulb and
extending to the petrous portion. A small residual
lumen is present.
• The optimal treatment would be
A. carotid artery stent placement
B. systemic anticoagulation with unfractionated
heparin
C. carotid exploration
D. external carotid-internal carotid (ECIC) bypass
E. low molecular weight heparin (30 mg/kg/day)
•
•
•
•
•
•
•
•
•
•
•
•
•
Blunt carotid artery injuries are potentially devastating injuries due to neurologic complications
Early detection and treatment remain the goals of management
hyperextension/rotation injuries sustained in high-impact motor vehicle crashes
much smaller percentage are caused by a direct blow to the neck
Five different mechanisms for the development of traumatic carotid artery:
– direct trauma to the artery
– hyperextension-rotation of the head with stretching of supra-aortic vessels
– blunt intra-oral trauma
– basal skull or mandibular fractures
– combined chest-head injuries with carotid stretching
most common mechanism is a direct blow to the head with hyperextension-rotation of the neck, which
causes stretching of the internal carotid artery over the transverse processes of the first and second
cervical vertebrae
Carotid artery dissection typically causes headache or neck ache, followed after hours to days by focal
motor or sensory deficits
carotid four-vessel angiography remains the gold standard, CTA now
Treatment options: observation, antithrombotic therapy, open surgical repair of the affected carotid
artery, and endovascular carotid artery treatment
mainstay systemic anticoagulation with intravenous unfractionated heparin, which has been shown to
prevent progression of injury to a higher injury grade, to reduce the number of strokes, and to prevent
neurologic deterioration
Deteriorating or fluctuating neurologic symptoms might be an indication for surgical or endovascular
intervention
ECIC bypass is a surgical treatment option that is not indicated in this case.
Overall mortality resulting from posttraumatic carotid artery dissection varies from 5% to 40% with
neurologic morbidity from 12% to 80%, with bilateral lesions being the most severe
Q44
Q45
• A 53-year-old woman undergoes coronary artery bypass grafting and
mitral valve replacement with a St. Jude mechanical prosthesis. Warfarin
(Coumadin) therapy is initiated postoperatively, but on postoperative day
5 she has the acute onset of right calf pain, swelling, and tenderness.
Duplex scanning demonstrates acute deep venous thrombosis of the right
femoral-popiliteal veins. Intravenous unfractionated heparin therapy is
begun.
• On postoperative day 9, she has the acute onset of shortness of breath,
hypoxemia, and chest pain. Computed tomographic (CT) angiography
demonstrates multiple, bilateral pulmonary emboli. In addition, her
platelet count has fallen to 50,000.
Definitive management of this problem should be
A.
B.
C.
D.
E.
discontinuing unfractionated heparin
discontinuing unfractionated heparin and beginning low molecular
weight heparin
discontinuing unfractionated heparin and beginning argatroban
continuing unfractionated heparin and placing an inferior vena cava filter
continuing unfractionated heparin and immediate platelet transfusion
Q45
• A 53-year-old woman undergoes coronary artery bypass grafting and
mitral valve replacement with a St. Jude mechanical prosthesis. Warfarin
(Coumadin) therapy is initiated postoperatively, but on postoperative day
5 she has the acute onset of right calf pain, swelling, and tenderness.
Duplex scanning demonstrates acute deep venous thrombosis of the right
femoral-popiliteal veins. Intravenous unfractionated heparin therapy is
begun.
• On postoperative day 9, she has the acute onset of shortness of breath,
hypoxemia, and chest pain. Computed tomographic (CT) angiography
demonstrates multiple, bilateral pulmonary emboli. In addition, her
platelet count has fallen to 50,000.
Definitive management of this problem should be
A.
B.
C.
D.
E.
discontinuing unfractionated heparin
discontinuing unfractionated heparin and beginning low molecular
weight heparin
discontinuing unfractionated heparin and beginning argatroban
continuing unfractionated heparin and placing an inferior vena cava filter
continuing unfractionated heparin and immediate platelet transfusion
•
•
•
•
•
•
•
•
•
•
•
•
•
Q45
heparin-induced thrombocytopenia (HIT)
potentially catastrophic generalized thrombotic disorder triggered by heparin therapy
begins 4 to 14 days after initiation of therapy with intravenous unfractionated heparin, although it can be
associated with any type of heparin, given at any dose and by any route
risk of developing HIT is 2% to 5%
diagnosis should be suspected whenever the platelet count < 150,000, or decreased 50% or more from
baseline
Thrombotic complications are responsible for the severe morbidity and mortality associated with HIT
½-2/3 of patients with HIT may have thromboembolic complications
HIT has two major subtypes
Type 1 is associated with a mild thrombocytopenia, usually occurs within 4 days of starting therapy, is not
immune mediated, appears to be caused by a direct agglutinating effect of heparin on platelets, is not
associated with thrombosis, and resolves despite the continuation of heparin therapy
HIT type 2 is associated with severe thrombocytopenia and/or a significant fall in the baseline platelet
count, usually occurring 4 to 14 days after heparin therapy is initiated. It is immune mediated and may be
associated with both venous and arterial thrombosis. Type 2 HIT is generally associated with intravenous
infusion of unfractionated heparin, but has also been reported with subcutaneous low-dose heparin,
heparin flushes, heparin-coated catheters, and low molecular weight heparins (LMWH)
immediate discontinuation of unfractionated
Start direct thrombin inhibitor such as argatroban, bivalirudin, or lepirudin - inhibit the formation of fibrinbound thrombin, preventing thrombus extension and growth.
Platelet transfusion is contraindicated because it can promote thrombosis in the setting of HIT
Q46
• Blocks glycoprotein IIb/IIIa receptor
A.
B.
C.
D.
E.
Aspirin
Clopidogrel (Plavix)
Abciximab (Reopro)
Cilostazol (Pletal)
Ibuprofen
Q46
• Blocks glycoprotein IIb/IIIa receptor
A.
B.
C.
D.
E.
Aspirin
Clopidogrel (Plavix)
Abciximab (Reopro)
Cilostazol (Pletal)
Ibuprofen
Aspirin
•
relatively weak antiplatelet agent - blocks conversion of arachidonic acid to thromboxane by permanently
inactivating the cyclo-oxygenase activity of the prostaglandin synthase-1 (COX-1) and prostaglandin synthase-2
(COX-2)
•
effect lasts for the lifetime of the platelet
•
cessation of aspirin 5 days before operation
Q46
Clopidogrel (Plavix) and ticlopidine (Ticlid)
•
thienopyridenes with strong platelet inhibitory properties
•
selectively inhibit ADP receptor-mediated platelet aggregation
•
ticlopidine can cause thrombocytopenic purpura and neutropenia
•
clopidogrel should be discontinued at least 5 to 7 days before elective operations
•
If an emergency operation is required sooner, then platelet transfusions may be required
Abciximab (Reopro)
•
inhibit the platelet glycoprotein IIb/IIIa receptor
•
These drugs represent the most potent and expensive antiplatelet agents
•
used in patients at high risk for adverse coronary events
•
Bleeding complications are significantly increased, and severe thrombocytopenia occurs in 1% to 2% of patient.
•
The antiplatelet effects usually disappear within 12 hours
Cilostazol (Pletal)
•
reversible phosphodiesterase III inhibitor that allows for increased availability of cAMP, leading to vasodilation and
platelet inhibition
•
used to improve walking distance in patients with intermittent claudication
•
relatively weak inhibitor of platelet aggregation, and co-administration with aspirin or warfarin does not lead to
significant changes in coagulation parameters
•
bleeding is a reported side effect, so discontinue at least 5 to 7 days before elective operation
Nonsteriodal anti-inflammatory drugs (NSAIDs)
•
inhibit thromboxane-dependent platelet function by reversibly inhibiting COX-1
•
All platelet effects are reversed within 24 hours of drug cessation
Q12
Question: At what spinal level does the spinal artery of
Adamkiewicz usually arise?
T8-L1
Q12
Q11
• Which of the following statements about thromboangiitis
obliterans (Buerger's disease) is TRUE?
A. Women outnumber men 4:1
B. It is caused by a primary arterial infection with chlamydia
C. In a smoker, tobacco withdrawal should be gradual to
avoid rebound arterial vasospasm
D. It is characterized by thrombotic occlusions of small- and
medium-sized arteries
E. Despite complete abstinence from nicotine, most patients
eventually progress to major limb loss
Q11
• Which of the following statements about thromboangiitis
obliterans (Buerger's disease) is TRUE?
A. Women outnumber men 4:1
B. It is caused by a primary arterial infection with chlamydia
C. In a smoker, tobacco withdrawal should be gradual to
avoid rebound arterial vasospasm
D. It is characterized by thrombotic occlusions of smalland medium-sized arteries
E. Despite complete abstinence from nicotine, most patients
eventually progress to major limb loss
•
•
•
•
•
•
•
•
•
•
Q11
Thromboangiitis obliterans (Buerger's disease)
chronic arterial inflammatory condition of unknown etiology
arterial occlusion in medium and small extremity arteries
Major risk factors for atherosclerosis must be absent, proximal
sources of emboli must be excluded, as well as underlying
autoimmune disease and hypercoagulable states
Both men and women can be affected, but most male
Many patients develop a form of superficial thrombophlebitis that
can be helpful in establishing the diagnosis
Complete abstinence from tobacco in all forms (including chewing
tobacco and snuff) is the only known effective treatment
Most patients are unable to quit smoking
If nicotine exposure is not curtailed, amputation rates can approach
80% to 90%
Cessation of tobacco use can reduce this rate by 50%
ABSITE REVIEW
Vascular
Jessica O’Connell, MD
January 25, 2012
ABSITE REVIEW
Vascular & Orthopedics
Jessica O’Connell, MD
February 23, 2011
•
•
A.
B.
C.
D.
E.
F.
A 68-year-old woman with hypertension, coronary artery disease, and a long
history of Crohn's disease present with a 20-lb weight loss and deep, aching
abdominal pain after eating, severe enough that she has markedly decreased her
food intake. She has never been operated on for Crohn's disease of the terminal
ileum, which has required only one hospitalization and has been previously wellcontrolled with mesalamine (Pentasa).
Physical examination shows a flat, soft, nondistended abdomen without masses.
Rectal examination is normal and stool is hemoccult negative. Abdominal films
show no evidence of obstruction. The abdominal-pelvic computed tomographic
(CT) scan shown is obtained.
The next step in her management should be
esophagogastroduodenoscopy
capsule endoscopy
visceral angiogram
ileocecal resection
colonoscopy
Q1
•
•
A.
B.
C.
D.
E.
F.
A 68-year-old woman with hypertension, coronary artery disease, and a long
history of Crohn's disease present with a 20-lb weight loss and deep, aching
abdominal pain after eating, severe enough that she has markedly decreased her
food intake. She has never been operated on for Crohn's disease of the terminal
ileum, which has required only one hospitalization and has been previously wellcontrolled with mesalamine (Pentasa).
Physical examination shows a flat, soft, nondistended abdomen without masses.
Rectal examination is normal and stool is hemoccult negative. Abdominal films
show no evidence of obstruction. The abdominal-pelvic computed tomographic
(CT) scan shown is obtained.
The next step in her management should be
esophagogastroduodenoscopy
capsule endoscopy
visceral angiogram
ileocecal resection
colonoscopy
Q1
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
history of Crohn's disease over a long period of time is somewhat confusing
Think about partial obstruction from Crohn's disease in terminal ileum
abdominal films & CT – no obstruction or bowel wall thickening
history is suggestive of chronic mesenteric ischemia
aching (rather than cramping) abdominal pain after eating, weight loss, and food
fear
CT - heavy calcification in aorta
dense calcification SMA take-off
visceral angiogram with lateral views of the aorta
Visceral angina is commonly seen in women
classic triad of weight loss, postprandial epigastric pain 30 to 45 minutes after
eating, and avoidance of eating.
frequently lost so much weight that intra-abdominal malignancy is a concern
commonly undergo an extensive evaluation before correct dx
duplex scanning of the aorta/visceral vessels may be adequate
conventional angiography with both anteroposterior and lateral views
Variety of therapeutic approaches
–
–
–
–
•
antegrade bypass grafting from aorta
retrograde bypass grafting from infrarenal aorta or one of iliac arteries
endarterectomy of the affected vessels
percutaneous approaches PTA +/- stent
Whether all or only the symptomatic mesenteric vessels need be re-vascularized is
controversial. Most studies favor complete revascularization of all of the diseased
vessels.
Q1
Q2
Which of the following is the most appropriate candidate for protected
carotid-artery stenting?
A.
Healthy 60-year-old man with amaurosis fugax of the left eye and
an 80% stenosis of the left internal carotid artery (ICA)
B. Healthy 70-year-old woman with a 50% asymptomatic stenosis of
the left ICA
C. 69-year-old man with severe congestive heart failure, left
ventricular ejection fraction of 20%, and a 60% asymptomatic
stenosis of the left ICA
D. 72-year-old man with chronic obstructive pulmonary disease
(FEV1 =0.40), episodes of intermittent right arm weakness, and
90% stenosis of the left ICA
E. 60-year-old diabetic man with unexplained right eye blindness
and 50% stenosis of the left ICA
Q2
Which of the following is the most appropriate candidate for protected
carotid-artery stenting?
A.
Healthy 60-year-old man with amaurosis fugax of the left eye and
an 80% stenosis of the left internal carotid artery (ICA)
B. Healthy 70-year-old woman with a 50% asymptomatic stenosis of
the left ICA
C. 69-year-old man with severe congestive heart failure, left
ventricular ejection fraction of 20%, and a 60% asymptomatic
stenosis of the left ICA
D. 72-year-old man with chronic obstructive pulmonary disease
(FEV1 =0.40), episodes of intermittent right arm weakness, and
90% stenosis of the left ICA
E. 60-year-old diabetic man with unexplained right eye blindness
and 50% stenosis of the left ICA
High Risk - Medical:
•
“High Risk for CEA”
clinically significant cardiac disease
– congestive heart failure, abnormal stress test, EF <30%, need for open-heart surgery, MI
within 4 weeks, CABG within 6 months
•
•
•
severe pulmonary disease
Dialysis dependent renal failure
age > 80 years
High Risk - Surgical:
•
•
•
•
•
•
•
contralateral carotid occlusion
contralateral laryngeal nerve palsy
previous radical neck surgery
radiation therapy to the neck
recurrent stenosis after endarterectomy
high lesion (above C2)
Tracheostomy
NASCET Results
•
North American Symptomatic Carotid Endarterectomy Trial
•
significant benefit of CEA in patients with 70% to 99%
symptomatic stenosis
•
Two-year ipsilateral stroke risk
– 26% in the medically treated patients
– 9% in the CEA group (P <.001; ARR 17.0%; NNT = 6)
Beneficial effect of carotid endarterectomy in symptomatic patients with highgrade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial
Collaborators. N Engl J Med. 1991 Aug 15;325(7):445-53.
NASCET Results
NASCET Results
NASCET Results
Asymptomatic Carotid Atherosclerosis Study
(ACAS)
•Multicenter, randomized, prospective
•Medical management vs. medical management & CEA
•Asymptomatic patients with ≥60% ICA stenosis
•Endpoints: stroke or death
•Results: stroke / death (at 5 years)
•Medical Group: 11%
•Surgical Group: 5.1% (53% RRR; P = .004)
•Surgical Morbidity / Mortality: 1.5%
•Major Angio related Morbidity / Mortality: 1.2%
•Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for
asymptomatic carotid artery stenosis. JAMA. 1995 May 10;273(18):1421-8.
Carotid Revascularization Endarterectomy
vs. Stenting Trial (CREST)
•Multicenter, randomized, prospective, 2502 patients
•CEA vs. CAS
•Symptomatic patients with ICA stenosis
• ≥50% on angio
• ≥70% on US
• ≥70% on CTA or MRA (if US 50-69% on US)
•Asymptomatic patients with ICA stenosis
• ≥60% on angio
• ≥70% on US
• ≥80% on CTA or MRA (if US 50-69% on US)
•Endpoint: periprocedural (randomization to ~1 month postop)
stroke, MI, death OR ipsilateral stroke up to 4 years
Carotid Revascularization Endarterectomy
vs. Stenting Trial (CREST)
CAS
CEA
P-value
Overall Endpoints
7.2%
6.8%
0.51
Stroke/death
6.4%
4.7%
0.03
Symptomatic stroke/death
8.0%
6.4%
0.14
Asymptomatic stroke/death
4.5%
2.7%
0.07
Periproc. Endpoints
5.2%
4.5%
0.38
Periproc. Death
0.7%
0.3%
0.18
Periproc. Stroke
4.1%
2.3%
0.01
Peroproc. MI
1.1%
2.3%
0.03
Postproc. Ipsilateral Stroke
2.0%
2.4%
0.85
Periproc. Cranial Nerve Palsies
0.3%
4.7%
0.07
Carotid Revascularization Endarterectomy
vs. Stenting Trial (CREST)
•
•
•
•
•
•
•
Periprocedural Stroke more likely after CAS
MI more likely after CEA
QOL worse after stroke compared to MI
Younger (<70 years) patients had slightly fewer events after CAS
Older patients had fewer events after CEA
More cranial nerve injuries with CEA
Postprocedural stroke similar – clinical durability - CREST following out 10 yrs.
Q7
• A 45-year-old woman undergoes angiography for severe
hypertension, as shown. Which of the following
statements about the lesion(s) shown is TRUE?
A.
B.
C.
D.
The most likely etiology is atherosclerosis
Lesions > 2.0 cm are associated with a high incidence of rupture
The most common location is in the main renal artery
Surgical repair improves control of hypertension in 60% of
patients
E. Lesions < 2.0 cm should be managed nonoperatively
Q7
• A 45-year-old woman undergoes angiography for severe
hypertension, as shown. Which of the following
statements about the lesion(s) shown is TRUE?
A.
B.
C.
D.
The most likely etiology is atherosclerosis
Lesions > 2.0 cm are associated with a high incidence of rupture
The most common location is in the main renal artery
Surgical repair improves control of hypertension in 60% of
patients
E. Lesions < 2.0 cm should be managed nonoperatively
•
•
•
•
aneurysm of the renal artery
0.09% of the general population
incidental
most common etiology arterial fibrodysplasia
–
–
underlying arterial matrix disruption leads to aneurysm formation, particularly at branch points where
discontinuities in the internal elastic lamina are common, even in healthy patients
Multiparous women
•
•
•
•
•
•
•
•
•
During the latter stages of gestation, an alteration in hormone and enzyme activity contributes to the tissue relaxation
necessary for parturition. Sustained release of these matrix-altering substances
35-year experience with 252 renal artery aneurysms in 168 patients at the University of Michigan,
most asymptomatic, average size 1.5 cm
60% of patients undergoing repair had a significant decline in blood pressure postoperatively, while
taking fewer antihypertensive medications
Late renal artery rupture did not occur in the nonoperative patients, but this group saw no change
in their hypertension
average number of renal artery aneurysms per patient was 1.5. Most patients had solitary
aneurysms, but 53 had multiple renal artery aneurysms. Bilateral aneurysms occurred in 32
patients
The most common location - bifurcation or the first order renal artery branch not main renal artery
itself.
Lesions > 2 cm in diameter are not associated with a higher incidence of rupture compared with
lesions < 2 cm
In fact, patients with aneurysms < 2 cm in diameter can have a significant improvement in their
hypertension and should be offered surgical resection
Most aneurysms 1.5 to 2 cm in diameter and all those larger than 2 cm in diameter, regardless of
blood pressure status, should be treated surgically if their anatomic characteristics suggest a
relatively noncomplex renal artery construction and the procedure is undertaken by an experienced
surgeon
Q7
Q4
Question: what nerve is entrapped in carpal tunnel syndrome?
Median nerve
Question: most common cause of carpal tunnel syndrome?
other causes?
idiopathic
overuse syndrome
May be seen in conjunction with:
- Colles or Smith's fractures
- rheumatoid arthritis
- gout
- diabetes
- hypothyroidism
- amyloidosis
Q5
Question: What is the most frequently injured carpal bone?
scaphoid
Question: What is the classic presentation of a scaphoid fracture?
tenderness in anatomical snuffbox
Q26
• A 65-year-old diabetic woman has an ulcer on her
toe, as shown. Which of the following statements is
TRUE?
A.
Percutaneous angioplasty has no role in the
management of this patient
B. The presence of palpable pulses effectively
excludes the diagnosis of significant arterial
occlusive disease
C. Arterial bypass will prevent amputation
D. The patency of the vessels in the foot will be
greater than in the calf
E. The location and number of arterial stenoses
predict primary amputation
Q26
• A 65-year-old diabetic woman has an ulcer on her
toe, as shown. Which of the following statements is
TRUE?
A.
Percutaneous angioplasty has no role in the
management of this patient
B. The presence of palpable pulses effectively
excludes the diagnosis of significant arterial
occlusive disease
C. Arterial bypass will prevent amputation
D. The patency of the vessels in the foot will be
greater than in the calf
E. The location and number of arterial stenoses
predict primary amputation
• A recent study of 104 patients with diabetes mellitus Q26
and foot ulcers who were evaluated with arteriography
• arterial stenosis or occlusion in 103 patients
• Significant stenoses were found in patients with
palpable foot pulses and normal ankle brachial indices
• popliteal and infrapopliteal region
• vessels in the foot relatively spared
• Nearly 25% of patients could be treated with
percutaneous angioplasty to improve wound healing
and 10% required arterial bypass procedures
• Technical failures occurred in 15% of angioplasty and in
25% of bypass procedures
• limb salvage was achieved in 78% of patients with 44%
requiring amputation of single or multiple digits.
Q30
• A 78-year-old man who has a 6-month
history of weight loss and
postprandial pain develops the abrupt
onset of severe abdominal pain. The
lateral aortogram shown is obtained.
• Which of the following statements
about this condition is TRUE?
A. The prognosis is better than for
mesenteric venous thrombosis
B. Mortality is greater than 75%
C. Survival rates have improved over
the last 40 years
D. Prognosis is independent of the
etiology of the ischemia
E. This disease is usually diagnosed
early in its course
Q30
• A 78-year-old man who has a 6-month
history of weight loss and
postprandial pain develops the abrupt
onset of severe abdominal pain. The
lateral aortogram shown is obtained.
• Which of the following statements
about this condition is TRUE?
A. The prognosis is better than for
mesenteric venous thrombosis
B. Mortality is greater than 75%
C. Survival rates have improved over
the last 40 years
D. Prognosis is independent of the
etiology of the ischemia
E. This disease is usually diagnosed
early in its course
• no filling of the superior mesenteric or inferior
mesenteric arteries
• Late filling of the celiac artery 2 cm distal to
the origin
• Quantitative analysis of 45 observational
studies of 3692 patients
– venous thrombosis 32% mortality
– arterial emboli 54%
– nonocclusive ischemia 72.7%
– acute arterial thrombosis 77.4%
Q30
Q6
Question: What are Kanavel's four signs of flexor tenosynovitis?
1) flexed posture of affected digit
2) tenderness along the sheath with erythema
3) pain on passive extension of DIP joint
4) fusiform swelling (sausage-like finger)
Rest
Splint
Steroid
injection
Surgery
Q7
Question: Which nerve is injured in anterior dislocations of the
humerus?
axillary nerve
Q8
Question:
What is a Jefferson fracture? what
type of injuries cause this fracture?
burst fracture of anterior and
posterior arch of C1
- lateral displacement of lateral
masses of C1
- usually an axial load injury
Question: What is a Hangman's fracture?
bilateral fracture of lateral masses of C2
Q9
Q10
Question: What is a Chance fracture?
transverse fracture through body of L3
-often seen in drivers with improperly
applied lap belts
-associated with small bowel injury in 50%
- many recommend laparotomy for any pt
with this fracture
Q43
• The most appropriate initial management for
a posterior hip dislocation would be
• computed tomography (CT) to evaluate for
intra-articular fragments prior to reduction
A. conscious sedation with closed reduction as
soon as possible
B. placement of a traction splint
C. bed rest and application of skeletal traction
to reduce the dislocation
D. immediate operative reduction
Q43
• The most appropriate initial management for a
posterior hip dislocation would be
• computed tomography (CT) to evaluate for intraarticular fragments prior to reduction
A. conscious sedation with closed reduction as
soon as possible
B. placement of a traction splint
C. bed rest and application of skeletal traction to
reduce the dislocation
D. immediate operative reduction
E. computed tomography (CT) to evaluate for intraarticular fragments prior to reduction
• Hip dislocation is often caused by a force applied to the femur and is most Q43
commonly associated with fractures of the acetabulum or femoral head
• Motor vehicles crashes are a common mechanism
• Force applied to an abducted hip can result in anterior dislocation
• striking the knee on the dashboard with the hip flexed and adducted
results in posterior dislocations
• Posterior dislocations often associated with fractures of the posterior wall
of the acetabulum
• Once the hip has been completely dislocated posteriorly, it may appear
shortened and internally rotated
• Sometimes femoral head or acetabular fractures are associated with this
dislocation
• Sciatic nerve injuries are present in up to 15% of posterior hip dislocations
• Closed reduction is usually accomplished by longitudinal traction, followed
by gentle abduction and external rotation
• Stability of the reduction should be determined at the time of closed
reduction
• Open reduction and internal fixation is indicated only if the reduction is
unstable and associated with a posterior wall fracture
Q11
Question: why is it so important to not
miss a scaphoid fx?
proximal scaphoid receives its blood
supply from the distal bone
- a missed fx can lead to avascular
necrosis of proximal scaphoid
Q3
Question: what is a felon?
infection of the pulp of the fingertip that can lead
to deep ischemic necrosis because of
compartmentalizing septa
- pulp space should be drained by dividing
septa
Question: what is paronychia?
infections around margins of nail plate
- caused by hangnails, manicure trauma,
small foreign bodies
- usually Staph A.- treat early cases w/
warm soak, abx, drain abscesses
Q3
Felon
Paronychia