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(BQ) Part 1 book Surgical recall presentation of content: Pediatric surery, thoracic surery, neurosurery, neurosurery, tneurosurery, orthopaedic surery, surical pathonomonic microvinettes, omplications microvinettes, blood microvinettes, medical treatments of surical dianoses,...
Chapter 66 / Vascular Surgery 515 Axillofemoral bypass gra —gra not in a normal vascular path; usually, the gra goes from the axillary artery to the femoral artery and then from one femoral artery to the other (fem-fem bypass) What is an endovascular repair? Placement of a stent proximal and distal to an AAA through a distant percutaneous access (usually through the groin); less invasive; long-term results as good as open 0' fr h What is an extra-anatomic bypass gra ? CLASSIC INTRAOP QUESTIONS DURING AAA REPAIR Which vein crosses the neck of the AAA proximally? Renal vein (le ) What part of the small bowel crosses in front of the AAA? Duodenum Which large vein runs to the le of the AAA? IMV Which artery comes o the middle of the AAA and runs to the le ? IMA Which vein runs behind the RIGHT common iliac artery? LEFT common iliac vein Which renal vein is longer? Le WhiteKnightLove 516 Section II / General Surgery MESENTERIC ISCHEMIA Chronic Mesenteric Ischemia What is it? Chronic intestinal ischemia from long-term occlusion of the intestinal arteries; most commonly results from atherosclerosis; usually in two or more arteries because of the extensive collaterals What are the symptoms? Weight loss, postprandial abdominal pain, anxiety/fear of food because of postprandial pain, heme occult, diarrhea/vomiting What is “intestinal angina”? Postprandial pain from gut ischemia What are the signs? Abdominal bruit is commonly heard How is the diagnosis made? A-gram, duplex, MRA What supplies blood to the gut? Celiac axis vessels SMA IMA What is the classic nding on A-gram? wo of the three mesenteric arteries are occluded, and there is atherosclerotic narrowing of the third patent artery What are the treatment options? Bypass, endarterectomy, angioplasty, stenting Acute Mesenteric Ischemia What is it? Acute onset of intestinal ischemia What are the causes? Emboli to a mesenteric vessel from the heart Acute thrombosis of long-standing atherosclerosis of mesenteric artery What are the causes of emboli from the heart? AFib, MI, cardiomyopathy, valve disease/endocarditis, mechanical heart valve WhiteKnightLove Chapter 66 / Vascular Surgery 517 What drug has been associated with acute intestinal ischemia? Digitalis To which intestinal artery emboli preferentially go? Superior Mesenteric Artery (SMA) What are the signs/symptoms of acute mesenteric ischemia? Severe pain—classically “pain out of proportion to physical exam,” no peritoneal signs until necrosis, vomiting/ diarrhea/hyperdefecation, heme stools What is the classic triad of acute mesenteric ischemia? Acute onset of pain Vomiting, diarrhea, or both History of AFib or heart disease What is the gold standard diagnostic test? Mesenteric A-gram What is the treatment of a mesenteric embolus? Perform Fogarty catheter embolectomy, resect obviously necrotic intestine, and leave marginal looking bowel until a “second look” laparotomy is performed 24 to 72 hours postoperatively What is the treatment of acute thrombosis? Papaverine vasodilator via A-gram catheter until patient is in the OR; then, most surgeons would perform a supraceliac aorta gra to the involved intestinal artery or endarterectomy; intestinal resection/second look as needed MEDIAN ARCUATE LIGAMENT SYNDROME What is it? Mesenteric ischemia resulting from narrowing of the celiac axis vessels by extrinsic compression by the median arcuate ligament What is the median arcuate ligament comprised of? Diaphragm hiatus bers What are the symptoms? Postprandial pain, weight loss What are the signs? Abdominal bruit in almost all patients WhiteKnightLove 518 Section II / General Surgery How is the diagnosis made? A-gram What is the treatment? Release arcuate ligament surgically CAROTID VASCULAR DISEASE Anatomy Identify the following structures: Internal carotid artery External carotid artery Carotid “bulb” Superior thyroid artery Common carotid artery (Shaded area: common site of plaque formation) What are the signs/symptoms? Amaurosis fugax, IA, RIND, CVA De ne the following terms: Amaurosis fugax emporary monocular blindness (“curtain coming down”): seen with microemboli to retina; example of IA TIA Transient Ischemic Attack: focal neurologic de cit with resolution of all symptoms within 24 hours RIND Reversible Ischemic Neurologic De cit: transient neurologic impairment (without any lasting sequelae) lasting 24 to 72 hours CVA CerebroVascular Accident (stroke): neurologic de cit with permanent brain damage What is the risk of a CVA in patients with TIA? 10% a year WhiteKnightLove Chapter 66 / Vascular Surgery 519 What is the noninvasive method of evaluating carotid disease? Carotid ultrasound/Doppler: gives general location and degree of stenosis What is the gold standard invasive method of evaluating carotid disease? A-gram What is the surgical treatment of carotid stenosis? Carotid EndArterectomy (CEA): the removal of the diseased intima and media of the carotid artery, o en performed with a shunt in place What are the indications for CEA in the ASYMPTOMATIC patient? Carotid artery stenosis 60% (greatest bene t is probably in patients with 80% stenosis) What are the indications for CEA in the SYMPTOMATIC (CVA, TIA, RIND) patient? Carotid stenosis Before performing a CEA in the symptomatic patient, what study other than the A-gram should be performed? Head C In bilateral high-grade carotid stenosis, on which side should the CEA be performed in the asymptomatic, right-handed patient? Le CEA rst, to protect the dominant hemisphere and speech center What is the dreaded complication a er a CEA? Stroke (CVA) What are the possible postoperative complications a er a CEA? CVA, MI, hematoma, wound infection, hemorrhage, hypotension/hypertension, thrombosis, vagus nerve injury (change in voice), hypoglossal nerve injury (tongue deviation toward side of injury— “wheelbarrow” e ect), intracranial hemorrhage What is the mortality rate a er CEA? 1% WhiteKnightLove 50% 520 Section II / General Surgery What is the perioperative stroke rate a er CEA? Between 1% (asymptomatic patient) and 5% (symptomatic patient) What is the postoperative medication? Aspirin (inhibits platelets by inhibiting cyclo-oxygenase) What is the most common cause of death during the early postoperative period a er a CEA? MI De ne “Hollenhorst plaque”? Microemboli to retinal arterioles seen as bright defects CLASSIC CEA INTRAOP QUESTIONS What thin muscle is cut right under the skin in the neck? Platysma muscle What are the extracranial branches of the internal carotid artery? None Which vein crosses the carotid bifurcation? Facial vein What is the rst branch of the external carotid? Superior thyroidal artery Which muscle crosses the common carotid proximally? Omohyoid muscle Which muscle crosses the carotid artery distally? Digastric muscle (T ink: Digastric Distal) Which nerve crosses approximately cm distal to the carotid bifurcation? Hypoglossal nerve; cut it and the tongue will deviate toward the side of the injury (the “wheelbarrow e ect”) Inte rnal c aro tid arte ry Hypo g lo s s al ne rve Exte rnal c aro tid arte ry Co mmo n c aro tid arte ry WhiteKnightLove Chapter 66 / Vascular Surgery 521 Which nerve crosses the internal carotid near the ear? Facial nerve (marginal branch) What is in the carotid sheath? Carotid artery Internal jugular vein Vagus nerve (lies posteriorly in 98% of patients and anteriorly in 2%) Deep cervical lymph nodes SUBCLAVIAN STEAL SYNDROME What is it? Arm fatigue and vertebrobasilar insu ciency from obstruction of the le subclavian artery or innominate proximal to the vertebral artery branch point; ipsilateral arm movement causes increased blood ow demand, which is met by retrograde ow from the vertebral artery, thereby “stealing” from the vertebrobasilar arteries Which artery is most commonly occluded? Le subclavian WhiteKnightLove 522 Section II / General Surgery What are the symptoms? Upper extremity claudication, syncopal attacks, vertigo, confusion, dysarthria, blindness, ataxia What are the signs? Upper extremity blood pressure discrepancy, bruit (above the clavicle), vertebrobasilar insu ciency What is the treatment? Surgical bypass or endovascular stent RENAL ARTERY STENOSIS What is it? Stenosis of renal artery, resulting in decreased perfusion of the juxtaglomerular apparatus and subsequent activation of the renin-angiotensin-aldosterone system (i.e., hypertension from renal artery stenosis) S te no s is What is the incidence? 10% to 15% of the U.S population have H N; of these, 4% have potentially correctable renovascular H N Also note that 30% of malignant H N have a renovascular etiology What is the etiology of the stenosis? 66% result from atherosclerosis (men women), 33% result from bromuscular dysplasia (women men, average age 40 years, and 50% with bilateral disease) Note: Another rare cause is hypoplasia of the renal artery WhiteKnightLove Chapter 66 / Vascular Surgery 523 What is the classic pro le of a patient with renal artery stenosis from bromuscular dysplasia? Young woman with hypertension What are the associated risks/ clues? Family history, early onset of H N, H N refractory to medical treatment What are the signs/symptoms? Most patients are asymptomatic but may have headache, diastolic H N, ank bruits (present in 50%), and decreased renal function What are the diagnostic tests? A-gram Maps artery and extent of stenosis (gold standard) IVP 80% of patients have delayed nephrogram phase (i.e., delayed lling of contrast) Renal vein renin ratio (RVRR) If sampling of renal vein renin levels shows ratio between the two kidneys 1.5, then diagnostic for a unilateral stenosis Captopril provocation test Will show a drop in BP Are renin levels in serum ALWAYS elevated? No: Systemic renin levels may also be measured but are only increased in malignant H N, as the increased intravascular volume dilutes the elevated renin level in most patients What is the invasive nonsurgical treatment? Percutaneous Renal Transluminal Angioplasty (PRTA)/stenting: With FM dysplasia: use PR A With atherosclerosis: use PR A/stent What is the surgical treatment? Resection, bypass, vein/gra interposition, or endarterectomy What antihypertensive medication is CONTRAINDICATED in patients with hypertension from renovascular stenosis? ACE inhibitors (result in renal insu ciency) WhiteKnightLove 524 Section II / General Surgery SPLENIC ARTERY ANEURYSM What are the causes? Women—medial dysplasia Men—atherosclerosis How is the diagnosis made? Usually by abdominal pain S U/S or C scan, in the O.R a er rupture, or incidentally by eggshell calci cations seen on AXR What is the risk factor for rupture? Pregnancy What are the indications for splenic artery aneurysm removal? Pregnancy, cm in diameter, symptoms, and in women of childbearing age What is the treatment for splenic aneurysm? Resection or percutaneous catheter embolization in high-risk (e.g., portal hypertension) patients POPLITEAL ARTERY ANEURYSM What is it? Aneurysm of the popliteal artery caused by atherosclerosis and, rarely, bacterial infection Po plite al arte ry Kne e How is the diagnosis made? Ane urys m Usually by physical exam S A-gram, U/S WhiteKnightLove ... year? g/kg/day (2 3.5) Children ages to 7? g/kg/day (2 2. 5) Children ages to 12? g/kg/day Youths ages 12 to 18? 1.5 grams/kg/day How many calories are in breast milk? PeDiA Ri BL 20 Kcal/30 cc... children? 4, 2, per hour: cc/ kg or the rst 10 kg o body weight cc/kg or the second 10 kg o body weight cc/ kg or every kilogram over the rst 20 (e.g., the rate for a child weighing 25 kg is 10... Premature infants/infants/children need more calories and protein/kg/day WhiteKnightLove 20 mEq KCl 527 528 Section III / Subspecialty Surgery What are the caloric requirements by age or the ollowing