This document contains a collection of review notes for the Canadian Vascular Surgery board exam. It was created by consolidating notes from various sources and exam prep materials over several years. The notes are intended to highlight essential information but may oversimplify some topics. Additional reading, especially of primary texts like Rutherford's Vascular Surgery, is recommended for a full understanding. The content will be updated over time with feedback and as exam expectations evolve.
This document contains a collection of review notes for the Canadian Vascular Surgery board exam. It was created by consolidating notes from various sources and exam prep materials over several years. The notes are intended to highlight essential information but may oversimplify some topics. Additional reading, especially of primary texts like Rutherford's Vascular Surgery, is recommended for a full understanding. The content will be updated over time with feedback and as exam expectations evolve.
This document contains a collection of review notes for the Canadian Vascular Surgery board exam. It was created by consolidating notes from various sources and exam prep materials over several years. The notes are intended to highlight essential information but may oversimplify some topics. Additional reading, especially of primary texts like Rutherford's Vascular Surgery, is recommended for a full understanding. The content will be updated over time with feedback and as exam expectations evolve.
Unofficial 2008 Review Notes University of Ottawa Anton Sara!ov" M# U!dated $une %" 200% C u r e o c c a s i o n a l l y " r e l i e v e o f t e n " c o n s o l e a l w a y s & A & 'ar( )*)+,)*%0 Canadian Vascular Surgery Minimum -at follows" is a collection of notes gleaned from multitude of scra!s" scri..les" summaries of te/ts 0!rimarily Ruterford and Moore1" and in,training written e/ams in Ottawa& Originally 2 started writing tings down in !re!aration for my Canadian and American Vascular 3oards& 2 did not find a unified edita.le collection of review notes anywere" ence 2 decided to do tis !ro4ect& 5ese notes are 6AR from .eing com!reensive& Also" .eing a uge fan of 7Made Ridiculously Sim!le8 series and 7-atever for 2diot9s8 fracise 0more .y necessity" rater tan .y coice1" 2 may ave oversim!lified tings a .it to ma:e it easier to understand and memori;e& So consider information critically& 5is is a com!osite .ody of wor: s!anning several years of study notes written .y te Canadian Vascular surgery fellows and wic were !assed on to te ne/t generation& 2 edited tese and added a few of im!ressions < .iases of mine own& My study !artners Wesam Abuznadah, MD" a fellow at U of Calgary and Hao Ming Wu, fellow at U of 3ritis Colum.ia" were instrumental wit several revisions of te draft& Our tan:s go to te generations of scri..lers and note ta:ers" to te 73ig R8" as well as to our staff surgeons& -e formed a google study grou!" and conduted almost daily conference meetings over S:y!e wic was el!ful& 5is is not a su.stitute for reading Ruterford or doing actual oral e/ams& 2 :now of several successful vascular surgeons wo never did read Ruterford from cover to cover .ut tey are 4ust !lain .rilliant and full of uni.ited genius& So unless you are all tat" read your 7.ig R8& 2 did& 5is is a wor: in !rogress& =ou can9t >uote wat9s written ere as te statements contained erein may all .e !ronounced .las!emous * years down te roadJ ?owever" tis is loosely .ased on wat9s e/!ected to :now on te written !art of te Canadian Vascular 3oard& 6eel free to email me at antonsara!ov@yaoo&com wit constructive ctiticism etc& 5o navigate" !ress C5RA and clic: on te item in te Content& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2 Canadian Vascular Surgery Minimum Contents 'RBO'C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )) )&Clinical ris: inde/esC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )) 2&?ow does 'ersantine scan wor:D &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2 E&Role of CA# screening !reo!D &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E F&CAR' studyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E *&Courage studyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E G&'O2SB studyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F +&Res!iratory assessment and fitness for toracotomyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F 8&Bagle criteriaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F %&Modified Aee criteria &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )* )0&-at are MB5SD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )* ))&Arterial MR2 studiesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G ?BMO#=NAM2CS AN# #O''ABRC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G )2&?emodynamic !rinci!lesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G )E& Non,invasive testing overviewC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )% )F&#o!!ler wave formsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )% )G&Resting A32 H advantages and disadavantagesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22 )+& Stress testing and A32C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F )8& B/tremity arterial du!le/ and stenosisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2G )%&Venous graft follow u!C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 28 20&-y does steal after fem,fem or a/,.ifem occur rarelyD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 28 2)&Carotid ultrasound H -asington" NASCB5 and BCS5 criteria &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 28 22&Normal Carotid and Verte.ral flow velocitiesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2% 2E&Consensus !anel on US criteria on stenosisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& E) 2F&Oter useful velocities measurement for carotids &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& EE 2*&6re>uency of Surveylence of :nown stenosis &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& EF 2G&5ranscranial #o!!ler &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& EF 2+& Renal artery US &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& E* 28&Mesenteric du!le/ &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& E+ 2%& US and BVAR &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& E8 E0&Ultrasound of 5rans!lantC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& E% E)&Ultrasound and cronic venous insufficiency &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F0 E2& Caracteristics of venous flowC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F) EE& Ultrasound and #ialysis access &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F2 A5?BROSCABROS2S < R2SI 6AC5ORS9 5JC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& FE EF&'ysiologic role of endotelium C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& FE E*&6actors im!ortant for aterosclerotic !la>ue develo!mentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& FE EG&Role of macro!ages in aterosclerosis" list macro!age secreted K6C &&&&&&&&&&&&&&&&&&&& FF E+&-at a!!ens in aterosclerosisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& FF E8&Stages in aterosclerosis and ty!es of !la>uesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& FF E%&Name different mediators secreted .y endoteliumC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F* F0& Bndotelial !rogenitor cellsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F* F)&Mecanism of action of Nitric o/ide" or Bndotelial #erived Rela/ing 6actorC &&&&&&& F* F2&Bffects of smo:ingC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F* Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age E Canadian Vascular Surgery Minimum FE&Mecanism of action of Angiotensin 22C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& FG FF& ACB2 effectsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F+ F*& -at are te effects of statinsD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F8 FG& $u!iter trial" 200%C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F8 F+&-at mecanical factors can in4ure endoteliumD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F% F8&Ste!s in intimal y!er!lasia develo!mentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& F% F%& ?ow can intimal y!er!lasia .e !reventedLtreatedD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *0 *0&?ow can R6 for aterosclerosis .e modifiedC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *0 *)&5arget for li!idsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *) *2&'A# and ris: reductionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *) *E&Conservative measures of treatment of claudicationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *F *F&## of claudicationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ** **&Ris: factors and mar:er of increased ris: for 'V#C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ** *G&-at en;ymatic deficiency is found in y!eromocysteinemiaD &&&&&&&&&&&&&&&&&&&&&&&&&&&&& ** S=M'A5?BC5OM= &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *G *+&?ow does sym!atectomy wor:D &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *G *8&2ndications for Aower e/tremity sym!atectomyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *G *%&Aum.ar sym!atectomyC outcome M &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *+ G0&U!!er e/tremity sym!atectomyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *8 VASCUA252S &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *8 G)&Raynaud9sC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& *8 G2&Connective tissue disordersC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G) GE& #iffirential diagnosis of !ositive ANAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G2 GF&VasculitisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G2 G*&5y!es of 5a:ayasu ArteritisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G2 GG&Kiant cell arteritisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& GF G+&3ecet disease diagnosisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G* G8&O5?BR Mid < small vessel vasculitisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& GG G%& Small vessel arteritisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G+ +0& Small vessel !atology leading to digital iscemiaC ## &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G+ +)&Arteritis associated wit aneurysm formationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G+ -B2R# < -ON#BR6UA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G+ +2&3uerger9s disease diagnostic criteriaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G+ +E&Angiogra!ic features of 3uerger9s diseaseC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G8 +F&Uncommon causes of aneurysms &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& G% +*&5y!es of collagenC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +0 +G& 6eatures of !seudo/antoma elasticumD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +0 ++&'atology of radiation vasculitisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +0 +8&Clinical syndromes associated wit cystic medial necrosisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +0 +%&Visceral S!lancnic Artery aneursymsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +) 80&Classification of s!lenic a& aneurysmsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +) 8)&2ndications and treatment for s!lenic artery aneurysm re!airC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +) 82&?e!atic a& aneurysmC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +2 8E&SMA" celiac" gastroe!i!loic aneurysmC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +2 8F& Renal a& aneurysmC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +E 8*&Com!le/ regional !ain syndrome C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +E Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age F Canadian Vascular Surgery Minimum 8G&5y!es of 6M#C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +F 8+& Most common arteries affected wit 6M#N &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +* 88& 'ortal y!ertension and .leedC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +* 8%&2ndication to treat vasc malfomationsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +* %0& ?am.urg classification of vascular malformationsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +G %)&Ili!!el,5renaunayC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +G %2& Sclerotera!yC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ++ %E& Vascular tumorsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ++ %F&Congenital defects and sym!tomsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ++ %*& 'ersistent sciatic arteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ++ %G& A..erant Rt& Su.clavian arteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +8 %+& -at is re>uired to ave a normal erectionD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +8 %8& Brectile disorderC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& +% BM3OA2SM" 5?ROM3OS2S < A2M3 2SC?BM2A 2N KBNBRAA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 80 %%& Causes of arterial occlusion in generalC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 80 )00& Most common sources of em.olismC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8) )0)& Most common sites of em.olisationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8) )02& Ateroem.olic Renal falureC i&e& !arencimal causesM &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 82 )0E& Causes of arterial trom.osisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8E )0F& Btiology of !ost o! acute Aeg iscemia !ost AAA re!airC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8E )0*& 2nfrainguinal graft trom.osisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8F )0G&2scemia < re!erfusion effects on organsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8* COAKUAA52ON < AN52COAKUAA52ON &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8G )0+& Summari;e coagulation cascadeC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8G )08& ?ow does #e/tran F0 wor:D &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 88 )0%&-arfarinC mecanism of action and com!licationsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8% ))0&Contraindications to warfarin tera!yC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8% )))&-at drugs affect warfarinC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %) 80& ?e!arin vs AM-?C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %) ))2&'rotamine mecanism of actionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %2 ))E&#irect 5rom.in ini.itorsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %2 #2SOR#BRS O6 COAKUAA52ON &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %2 ))F& ?25C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %2 ))*& ?y!ercoagula.le stateC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %E ))G& Anti!os!oli!id anti.odiesC ,AAC" ACA and SABC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %F ))+& Resistance to activated factor VC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %F ))8& Causes of mesenteric trom.osisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %F 8G& Common ac>uired causes of .leeding and teir treatmentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %* 5?ROM3OA=S2S &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %G ))%&5y!es of trom.olyticsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %G )20& Contraindications to trom.olysisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %+ )2)&5rom.olysis studies summaryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %+ )22&2ntrao!erative trom.olysisC ow toM &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& %% #V5 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )00 )2E&#iagnostic criteria for #V5C C#6M &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )00 )2F& R6 and outcomes for #V5C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )00 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age * Canadian Vascular Surgery Minimum )2*&#,dimer in diagosis of #V5C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0F )2G&-ays to treat #V5C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0F )2+&2ndications for 2VC filterC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0G )28&Com!lications of 2VC filterC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0G )2%&Migratory !le.itisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0+ )E0&Bffort trom.osisC classify &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0+ )E)&5reatment o!tions for !rimary a/illary vein trom.osisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0+ )E2&2liofemoral Venous trom.osisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0% C?RON2C VBNOUS 2NSU662C2BNC= &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0% )EE&Venous flow caracteristicsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )0% )EF&#eterminants of venous flowC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))0 )E*&Cause of Cronic venous insufficiencyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))0 )EG&-ave forms of venous !letysmogra!y in severe S6$ reflu/C &&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))) )E+&Venous disease assessmentC CBA' classification &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))E )E8&A!!roac to venous ulcersC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))F )E%&Name veins ligated during sa!enous vein stri!!ingC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))% )F0&-y does vein stri!!ing surgery failC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))% )F)&Venous claudicationC cause &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ))% )F2&Cronic 2VCLiliacLdee! vein o.structionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )20 )FE&SVC o.structionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )20 )FF&-y .y!asses for venous re!air are !rone to failureD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2) )F*&Aist AB !erforatorsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2) )FG&2ndications for !erforator ligationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )22 #2AA=S2S ACCBSS &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2E )F+&'rinci!les of AV6 creationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2E )F8&Access o!tions in Central Vein OcclusionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2F )F%&Com!lications of AV6 creationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2F )*0& 5reatment of AV6 stealC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2F A=M'?B#BMA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2* )*)&Aym! !ysiologyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2* )*2&Classify lym!edemaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2* )*E&Aong term com!lications of Aym!edemaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2+ )*F&5reatment of lym!edemaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2+ U''BR A2M3 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )28 )**&Kenearl causes of u!!er lim. iscemiaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )28 )*G&Sym!toms < signs of 5OSC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2% )*+&A!!roac to !t wit 5OS &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )2% )*8&Com!lications of )st ri. resectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E) )*%&2ndications for surgery of a su.clavian a& aneurysmC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E) )G0&Vi.ration wite fingerC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E) )G)&?y!otenar ?ammer SyndromeC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E) )G2&Occu!ational acro,osteolysisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E2 )GE&Atletic in4uriesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E2 Aower A2M3 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E2 )GF&#ifferential diagnosis of .ilateral lower lim. swellingC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E2 )G*&A!!roac to distal !eroneal a& &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )EE Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age G Canadian Vascular Surgery Minimum )GG&6ate of a claudicantC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )EF )G+&CA2 criteriaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E8 )G8&Natural / of !ts wit CA2C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E% )G%&5ASC classification for iliac and S6A lesionsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )E% )+0&3AS2A studyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F0 )+)&Vein advantages over !rosteticC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F) )+2&O!tions for .y!ass graft material in descending order of !referenceC &&&&&&&&&&&&&&&&&& )F) )+E&Syntetic grafts H caracteristicsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F2 )+F&Adverse effects of Vein arvestC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )FE )+*&B/!ected !atency of vascular grafts < !roceduresC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )FE )+G&Com!lications after infrainguinal revasculari;ationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )FG )++&Kraft surveilanceC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F8 )+8&2liac '5A H ris:s of !rocedureC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F% )+%&'rimary and secondary !atencyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )F% )80&5ests for evaluation of te donor iliac artery !rior to fem,femC &&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*) )8)&'o!liteal aneurysmC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*) )82&A!!roaces to !o! aneurysm re!airC advantages and disadvantages &&&&&&&&&&&&&&&&&&&&& )*2 )8E&Koals of !eri!eral aneurysm treatmentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*E )8F&Nerves encountered in !o!liteal a& e/!osureC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*E )8*&Cystic adventitial diseaseC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*E )8G& Angio findings in adventitial cystic disease &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*F )8+&Causes of !o!liteal a& occlusion in order of fre>uency& &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*F )88&5y!es of !o!liteal entra!mentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*F )8%&Causes of early lim. edema after a femoro,ti.ial KSV .y!ass &&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*G )%0&Causes of com!artment syndromeC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*G )%)&Calf com!artmentsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*8 )%2&Acute lim. iscemia classificationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*8 )%E&Am!utation level and .onesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*8 )%F&#efine different ty!es of am!utationsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )*8 )%*&5ests to use to select level of am!utationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G0 )%G&Com!lication of .elow :nee am!utationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G0 )%+&Com!are arterial" venous and neuro!atic ulcers& &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G) )%8&'ato!ysiologic mecanisms in dia.etic footC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G2 CARO52#S &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )GF )%%&3rances of B/ternal Carotid arteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )GF 200&2nternal carotid artery anatomyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )GF 20)& B/ternal carotid to internal carotid a& collateralsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )GF 202&Clinical !resentations of cere.ral syndromesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G* 20E&Visual syndromesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G+ 20F&2ndication for carotid du!le/C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G+ 20*&2CA and CCA #o!!ler !rofile &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )G8 20G&Carotid du!le/ artery stenosis criteriaC -asington Criteria &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+0 20+&Consensus !anel on US criteria on carotid stenosisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+0 208&Oter useful velocities measurement for carotids &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+) 20%&6re>uency of Surveillance of :nown asym!tomatic stenosis &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+2 2)0&Mecanisms of stro:eC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+2 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age + Canadian Vascular Surgery Minimum 2))&Aa. and investigations for 52AC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+E 2)2&Recurrent CVA after 52A or CVAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+G 2)E&5iming of CBA wit res!ect to CVA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )++ 2)F&Contraindications to CBA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )++ 2)*&Com!lications of CBAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+8 2)G&Conduct of CBAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+8 2)+&2ndication for BCA endarterectomyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+% 2)8&#ifficult access to 2CAC ig 2CA" difficult 2CA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+% 2)%&Nerves encountered during CBA H &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )+% 220&Nascet findingsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )80 22)&Asym!tomatic Carotid artery stenosis and ACAS findingsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )8) 222&Carotid !atcing H advantages and disadvantagesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )8F 22E&Recurrent stenosis after CBAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )8G 22F& Carotid sunt com!licationsD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )8+ 22*&CBA and CA3K H decision ma:ing in vasc surgeryC !& 8G &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )8+ 22G&CAS trialsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )88 228&A 2CA occlusion& -at do doD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%2 22%& Verte.ral insufficiencyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%2 2E0&Revasculari;ation of verte.ral arteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%E 2E)&#escri.e steal" outline treatmentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%E 2E2&3rances of su.clavian arteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%F 2EE&3rances of a/illary arteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%F 2EF&6eatures of s!ontaneous carotid dissectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%* 2E*&Carotid 6M#C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%G 2EG&B/tracranial Carotic artery aneurymsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%G 2E+&Carotid .ody tumorC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%+ 2E8& 2nnervation of carotid .odyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%8 MBSBN5BR2C 2SC?BM2AC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%8 2E%&-at are te non,aterosclerotic causes of cronic mesenteric iscemiaD &&&&&&&&&&&& )%8 2F0&Causes of intestinal iscemiaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%% 2F)&#o!!ler findings in mesenteric iscemiaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )%% 2F2&Common variations of Common ?e!atic ArteryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 200 2FE&5reatment of mesenteric iscemiaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 200 2FF&#ifferences .etween acute and cronic mesenteric iscemiaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20) 2F*&?ow to determine intrao!erative .owel via.ilityD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20) RBNOVASCUAAR #2SBASB &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20) 2FG&#ifferentiate Renovascular ?y!ertension from oter causes of ?5ND &&&&&&&&&&&&&&&&& 20) 2F+&Mecanism of renal ?5NC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 202 2F8&Ca!to!ril ne!rogramC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20E 2F%&Renal a& du!le/C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20F 2*0&Surgical causes of y!ertensionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20F 2*)&Causes of RV ?5N" RV y!ertensionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20F 2*2&RV ?5N treatment and resultsC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20* 2*E&2ndications of concomitant aortic and renal reconstructionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20+ 2*F&Renal artery aneurysm re!air indicationsC RA aneu &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 208 2**&A!!roac to renal arteriesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20% Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 8 Canadian Vascular Surgery Minimum 2*G&B/,vivo reconstructionC indications &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 20% 2*+&2ndication for re!air of renal artery in traumaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)0 AAA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)0 2*8&AAA e!idemiology and causeC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)0 2*%&'rinci!al matri/ fi.ers in aorta" wat canges are seen in AAAD &&&&&&&&&&&&&&&&&&&&&&&&&& 2)) 2G0&Ris: factors for AAA #B5BC52ONC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)) 2G)&Natural istory AAA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)2 2G2&Relevant C5 findings in !ts wit AAA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)2 2GE&R6 for AAA ru!ture &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)E 2GF&Ru!tured AAA managementC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)E 2G*&2nflammatory AAAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)F 2GG&2ndications for retro!eritoneal R' re!airC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)F 2G+&Anatomic criteria for BVARC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)F 2G8&5y!es of endolea:sC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)F 2G%&S!ecific com!lications of BVAR ,endovascular AAA re!air &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)* 2+0&6ollow u! after BVAR& Bndolea: treatmentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)* 2+)&#ream" BVAR ) and BVAR 2 findings &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)+ 2+2& ?arvard Medicare Registry study &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)+ 2+E& 2ndications for angio in !t wit AAAC angio for AAA &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)% 5?ORACOA3#OM2NAA ANBUR=SM &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)% 2+F&5oracoa.dominal aneurysm 05A1 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2)% 2+*&#ecision ma:ing in assessing !t wit 5AAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22) 2+G&Strategy for renal !rotection in 5AAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 222 2++&-y is te s!inal cord at ris: during re!air of 5AAD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 222 2+8&S!inal cord !rotection metods during 5A re!airC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22E 2+%&3leeding during 5AA" causeC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22* 280&-en sould we NO5 cover SCA in toracic endograftingD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22* AOR52C #2SSBC52ONC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22G 28)&Aortic #issectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22G AOR5O2A2AC OCCAUS2VB #2SBASB 0A2O#1 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22% 282&A!!roac to !t wit A2O#C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 22% 28E&2ndication for Bnd to Bnd vs Bnd to Side for A36C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E0 28F&2ndication for A/illo,.i,femoral KraftC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E) 28*&5y!es of endarterectomy& #iscuss aortic endarterectomy &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E2 28G&Causes of AV communications involving aorta and its9 .rancesC &&&&&&&&&&&&&&&&&&&&&&&& 2EF 28+&'otential !ysiologic and anatomic conse>uences of a large AV6C &&&&&&&&&&&&&&&&&&&&&& 2EF 288&Aortocaval fistulaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2EF COM'A2CA52ONS &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E* 28%&Cardiac and Res!iratory Com!lications of vascular surgeryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E* 2%0&2scemic neuro!atyC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2EG 2%)&Com!lications of aortic surgeryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E+ 2%2&Strategy to minimi;e renal damage during aortic clam!ingD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E8 2%E&Clinical caracteristics" ris: and diagnosis of iscemic colitisC &&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E8 2%F&Colon iscemia avoidance after AAA re!airC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2E% 2%*&?ow to !revent se/ual disfuntion wit aortic surgeryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F0 2%G&?ow to im!rove !elvic circulationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F0 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age % Canadian Vascular Surgery Minimum 2%+&2ncidence of com!lications wit different ty!e of accessC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F0 2%8&'seudoaneurysm formationC causes &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F0 2%%&'ost Angio !seudoaneurysmC wyD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F) E00&2ntraartearial drug in4ection H mecanism of in4ury < t/ &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F) E0)&-at increases contrast ne!ro!atyD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F2 E02&Advantages of low osmolarity contrast to com!ared to igD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FE E0E&Kado!entate #imeglumine a:a CO2M &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FE E0F&Com!lications of .lood transfusionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FE E0*&#ifference .etween seroma and lym!oceleD &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FE 2N6BC5B# KRA65 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FF E0G&Native vascular vessel infectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FF E0+&C5 findings for infected !rostetic graftC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FG E08&Ris: 6actors !redis!osing to graft infectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2FG E0%&'revention of graft infectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F+ E)0&2nvestigation of !t wit draining R groin wound !ost A36 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F8 E))&2nfected A36 graftC #raining sinus in groin !ost A36C a!!roac H &&&&&&&&&&&&&&&&&&&&&& 2F8 E)2&Classification of graft infectionC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F% &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2F% E)E&C5 findings of aortoenteric fistulaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*0 E)F&Selection of !ts for infected graft !reservationC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*0 E)*&Selection of infected graft for insitu re!lacementC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*0 E)G& Results of aortic graft infection treatmentC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*) E)+& Aorto,enteric fistulaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*) 5RAUMAC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*F E)8&Carotid a& in4ury and neurologic deficit& -en to fi/D &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*F E)%&5reatment of .lunt carotid in4uryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*F E20&Cest vascular traumaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2** E2)&Radiogra!ic clues to !otential .lunt aortic in4uryC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*+ E22&Most common .lunt vascular toracic in4uriesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*+ E2E&Conservative treatment of toracic aortic in4uriesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*+ E2F& A.dominal vascular traumaC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2*+ E2*&B/tremity trauma notesC &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2G0 E2G&5raumatic AV6C &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2G) Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )0 Canadian Vascular Surgery Minimum PREOP: 1. Clinical risk indexes: o Koldman Cardiac ris: inde/ o Modified Aee o #ets:y CR2 o Bagle CR2 o American ?eart Association guidelinesC o Varia.les consideredC age" recent M2" C?6" BCK a.n" aortic stenosis" emergency OR" !oor general ealt" intra,a.doLtoraci" aortic surgery& o O.4ective measuresC BCK H if a.normal" E fold increase in !erio! com!lications" if normal H not !redictiveM& B/ercise BCK , less a!!lica.le in vascular surgeryC su.o!timalLsu.ma/imal effort due to disa.ility" ig false,negative& ?olter H good !redictor if a.normal& )0O can9t inter!ret meaningfully" ence false !ositivesC due to BCK canges not due to CA#& Stress,5alliumC under conditions of near ma/imal coronary flow 0di!yridamoleLadenosine induced1" eterogenous !erfusion areas are identified& Reasona.le test to order if !t is deemed intermediate ris: .y clinical assessment& Kood alternative H do.utamine BC?O& NUCABAR MB#2C2NB 5BS5SC 'erfusion studiesC o Myoview H test of myocardial !erfusion only" o 'B5 H more so!isticated form of myoviewC tells were !erfusion is a!!ening distinguises scar vs via.le vs necrotic myocardium 3lood !ool studyC o MUKA H myocardial !erfusion AN# ventricular function& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )) Canadian Vascular Surgery Minimum 'rovides te most accurate assessment of AV6 StressC o Add !ersantine" do.utamine" adenosine& 2. How does Persantine scan work? o 3aseline tallium nucleotide scan is done o #i!yridamole is administered o #i!yridamole dilates coronary circulation o As a result" flow to NON,stenotic vessels is increased o Stenotic vessel distri.ution sows delayed early u!ta:e o On re!eat imaging" tallium gets into te remaining myocardium 0inter!reted as redistri.ution or delayed u!ta:e1 OR does not 0inter!reted as scar1 o AsideC di!yridamole 0or !ersantine1 is a !os!odiesterase ini.itor H will increase cAM'" decrease CaPP" and decrease !latelet aggregationM 5ASC 22 *0O of !ts wit 'V# ave CA# 2*O of !ts wit 'V# ave Carotid disease )0O of !ts wit Carotid disease ave 'V# E0O wit Carotid disease ave CA# 20O of !ts wit CA# ave Carotid disease )0O of !ts wit CA# ave 'V# Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )2 Canadian Vascular Surgery Minimum 3. Role of CAD screening preop? role undefinedM o CA# is !revalent" .ut rates of M2 are fairly low Aorta 2O" CBA )O" infrainguinal FO 0Ruterford1 o Cardiac screening detects !rimarly ?# sig stenosis Acute coronary syndrome does not occur wit most ?# significant stenosis Most autors state ris: stratification is im!recise at .est o Aong term .enefits of CA# revasculari;ation 0if it is !erformed1 may not a!!ly for !ts wit 'V#M 5ere are no validated invasive or non,invasive metods to 2# !la>ues tat are vulnera.le to disru!tion ?ence !reo! o!timi;ation sould aim at !la>ue sta.ili;ation 2t is agreed tere is role for 33 and statins !reo! -ell done negative !rovocative test ave ig N'V o 'ositive test" owever" does not ave ig ''V 4. CARP study: o Coronary Artery Revasculari;ation 'ro!yla/is 0CAR'1 trial o ?y!otesisC among sta.le !atients wit CA# tat is amena.le to CA3K or 'C2" coronary artery revasculari;ation !rior to elective surgery im!roves long,term survival& o multicenter" randomi;ed" controlled" coo!erative trial )8 Veterans Affairs Medical Centers& 'atients sceduled for aortic and infrainguinal vascular o!eration eligi.le o Screen,Q angio,Qrandomi;ed to revasc vs no revasc o Screened *800" randomi;ed *00 o ResultC revasculari;ation !rocedure delaysL!revents te vascular o!eration does not im!rove eiter sort, or long,term survival& 5. Courage study: 'redictive value of 'OS252VB !reo!erative !armacologic nuclear !erfusion scanning is 'OOR 0*,20O1 o N'V is e/cellent 0%8,)00O1 200G" Study settingC 'atients wit o cronic angina !ectoris" o sta.le !ost,myocardial infarction 0M21 !atients o asym!tomatic !atients wit o.4ective evidence of myocardial iscemia Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )E Canadian Vascular Surgery Minimum i&e& !ositive non,invasive tesingLscanning o 228+ !ts randomi;ed to eiter aggressive med tera!y vs 'C2 !lus tera!y o At * years" same num.er of !ts is angina free o No difference noted& o Role of 'C2 !reo! sould .e >uestionedM 6. POIS study: Multi!le SMAAA studies sowed .eneficial effect of 3eta .loc:ers on CV mortality in !erio!erative setting 0e&g&#BCRBASB trial1 5is was tested in a +000 !t RC5 in !ts undergoing non,cardiac surgery Meto!rolol vs !lace.o Overall tere was reduction in M2 .ut tere was increase in stro:e and overall mortality in Meto!rolol grou! for every )000 !atients treated" meto!rolol would !revent )* M2s .ut tere would .e an e/cess of eigt deats and five severe disa.ling stro:es effects attri.uted to ig dose 33 tat com!ound !erio!erative soc: recommendation is to use lower dose" start 33 early to allow accommodation of dose" and avoid e/tended release !re!aration& tt!CLLcme&medsca!e&comLviewarticleL*+F*2G 7. Respiratory assess!ent and fitness for t"oracoto!y: '65C if 6BV) Q G0O or #ACO Q G0O , will tolerate u! to !neumonectomy 6BV) and #ACO R G0O o Suantitative lung scan 2f !redicted !ost o! 6BV) and #ACO Q F0O May !rocede to surgery 2f ''V 6BV) and #ACO R F0O 'erform /ercise testingC o 2f VO2 ma/ Q 20 mlL:gLmin 'rocede to surgery )*,20 ml H GGO ris: of com!licatios Q 20 ml H )0O ris: of com!lications o 2f VO2 ma/ R )* mlL:gLmin 3eware of )00O ris: of com!lications 8. agle criteria: o Age Q +0 o #ia.etes o Angina Q class E o C?6 o 'rev M2 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )F Canadian Vascular Surgery Minimum o BCK canges o Aortic stenosis o Ventricular arrytmia 9. #odified $ee criteria 'redicts ris: of ma4or cardiac com!licationsC o #M 0insulin de!endent1 o CVAL52A o AnginaLM2L !revious CA3KL'5A o C?6 o Renal insufficiency Q )80 0Q 21 o ?ig ris: !rocedure A.do" toracic" aortic" visceral o cardiac ris: inde/ as .een validated in num.er of studies ris: of ma4or vasc com!lications is e>ual to te num.er of R6 s>uared Num.er of ris: factor Ri:s of ma4or cardiac com!lications 0 0&*O ) )&EO 2 FO E %O 10.%"at are #&S? 1MET T Can you ta:e care of yourselfD T Bat" dress" or use te toiletD T -al: indoors around te ouseD T -al: a .loc: or two on level ground at 2 to E m! or E&2 to F&8 :m !er D 4METs T #o ligt wor: around te ouse li:e dusting or wasing disesD T Clim. a fligt of stairs or wal: u! a illD T -al: on level ground at F m! or G&F :m !er D T Run a sort distanceD T #o eavy wor: around te ouse li:e scru..ing floors or lifting or moving eavy furnitureD T 'artici!ate in moderate recreational activities li:e golf" .owling" dancing" dou.les tennis" or trowing a .ase.all or foot.allD >10METs Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )* Canadian Vascular Surgery Minimum T 'artici!ate in strenuous s!orts li:e swimming" singles tennis" foot.all" .as:et.all" or s:iingD 11.Arterial #RI studies: o 2 # 5O6 o E # 5O6 o E # !ase contrast o E# 5O6 gadolinium !ase contrast H 3BS5 o 7s!in eco tecni>ue8 H .lac: .lood tecni>ue" for large a& visuali;ation o 7gradient eco se>uence8 H .rigt .lood" for smaller a& 0renal" !eri!eral1 H#OD'(A#ICS A(D DOPP$R: 12.He!odyna!ic principles: Stenosis causes local distur.ances in laminar flow o 2n fluid" in te stenotic segment velocity KOBS U' o U!on leaving stenotic segement velocity KOBS #O-N 5is interaction sets off a series of multidirectinal velocity vector forces 5ese vectors are !er!etuated along te course of te tu.e due to inertia 0fluid as mass1 o 5e more mass fluid as , te more inertia it as 5is leads to tur.ulence and energy losses o Commonly !ic:ed u! as !ressure dro!Lvelocity dro! off -it time" tese tu.rulant vectors 0driven .y inertia1 are redirected .y te viscosity forces into a laminar flow& 2t is an interaction of te disru!ted 6AO- in te stenotic area 0inter!lay .etween inertia and viscocity of te fluid1 and a given RBS2S5ANCB of a vessel 0defined .y radius and lengt1 tat will determine ow muc energy 0!ressure1 will .e lost during tis interaction& Reflected in Om9s lawC o Cange in te direction and a.solute velocity will result in energy losses o S!ar:s 0energy1 fly wen you scra!e0resistance1 te sidewal: at )00 :mL 0flow1 o OmC energy 0'ressure cange1UResistanceVflow Resistance R= 8L!" 4 o tis re!resents minimum resistance in te circuit" o determined .y te lengt" radius of te vessel and te viscocity 0# of te fluid& 5e energy dro! for a given flow will increase if :inetic contri.ution is added H i&e& if acceleration andLor deceleration is seen in te flow& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )G Canadian Vascular Surgery Minimum A hemod$nami% &e"sion o' (he )mhs* +a,- .oiseui++e*s . i /. ii = 0 1 R= 01 8L!" 4 . i /. ii 2 !ressure or energy cange S , flow W H coefficient of viscocity 'ressure gradient across te stenosis is increasedC o te longer te lesion" o te iger te density < viscosity" density or mass determines :inetic com!onent as well" 134& i
3
o te greater te diameter reduction Mos( im5o"(an( -ere can te energy in te flow .e lostD o Viscocity loss H see 'oiseulle e>uation H te longer" te narrower te stenosis , te greater te loss o 2nertial loss H :inetic energy 134& i
3 This is (he mos( signi'i%an( ,a$ (o +ose ene"g$ in (he %i"%u+a(ion 2n stenotic area" flow increasesX See ig velocity 4et on do!!ler &e+o%i($ %hange is seen a( (he en("an%e 6goes u5# and (he e7i( o' (he s(eno(i% segmen( 6goes do,n#8 9n bo(h %i"%ums(a%es, ene"g$ is dissi5a(ed: ;o i' $ou ha&e 3 s(enosis 3 %m ea%h, ene"g$ +oss ,i++ be M)RE (han a sing+e 4 %m s(enosis8 To(a+ &as%u+a" "esis(an%e- CollateralsC o Com!ensate for te occlusion of main conduit 0iliacLfemLti.1 o 're,e/isting vessels" some are formed in res!onse to y!o/ia o YonesC Stem Mid;one Re,entry vessels Segmental resistance 0iliacLfemoral OR collaterals1 P outflow resistance Segmental resistance increase wit iliacLS6A disease o Bven multi!le collaterals can never .ring down total resistance to normal once iliacLfemorals are occludedM OutflowC com.ined resistance of arterioles" ca!illaries" venules" and veins -it arterial disease" segmental resistance is increased 0occlusive disease1" and outflow resistance is reduced as a com!ensation 0dilation at rest1 o ?enceC #iseased lim.s always ave iger segmental resistance Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )+ Canadian Vascular Surgery Minimum Bven wit e/ercise relative dro! in outflow resistance is SMAAABR in diseased lim.s com!ared to normal 3ecause in tese !atient outflow is ma/imally dilated at rest <e"nou++i*s 5"in%i5+e- Hemod$nami% &e"sion o' (he +a, o' %onse"&a(ion o' ene"g$8 The '+uid*s ene"g$ is de(e"mined b$ o (he e7is(ing ban= a%%oun( 6.i 2 ini(ia+ 5"essu"e#, o i(s* densi($ > s5eed 6i8e8 =ine(i% ene"g$# o and e+e&a(ion abo&e g"ound 6g"a&i($#8 Wi(hou( '"i%(ion and ,i(h %on(inous '+o,, (he ene"g$ %on(en( "emains %ons(an(8 . i ? 4gh i ? 134& i
3 = . ii ? 4gh ii ? 13 4& ii
3 Z H density of .lood Relationsi! .etween :inetic" gravitational energy and !ressure o in a frictionless system Under steady flow" frictionless systemn , energy remains te same& Re$no+ds numbe"- &e"$ im5o"(an( numbe" o #imensionless >uantity& o Re!resents an inter!lay .etween inertial and viscous forces& o -en num.er is R 2000" local distur.ances are dam!ened .y viscous forces and flow is laminar& o R e =4&d i&e& Aaminar flow 0R20001 is favoured in viscous 0ig W1Llow density 0low Z1 fluids slower flow 0low velocity V1 smaller diameter of te conduit& So" if te velocity is increased 0as in stenotic iliac lesion during e/ercise1" te Re can rise and eventually cross 2000 mar: H turning flow into 5UR3UABN5& 5is translates into energy losses and !ressure dro! !ast stenosis& Outflow resistance reduction 0due to ma/imum vasodilation1 is designed to counteract tis .ut can9t fully com!ensate for te energy loss at te stenotic segment& Minimum lengt of tu.e needed to turn laminar flow into tur.ulent OR to re, esta.lis laminar flow is defined as an entrance lengtC o En("an%e +eng(h- L 7 =@1"1R e @=081A te lengt of te tu.e needed to cange a tur.ulent flow into laminar is smaller ifC o te radius of te tu.e is small Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )8 Canadian Vascular Surgery Minimum o te fluid is more viscous o te flow is slow
La5+a%e- Wa++ (ension = .1" Aarger tu.es ave larger wall tension& Aarger aneurysms are more !rone to ru!ture #o!!lerC '"eBuen%$ shi'( C'= 3 D o 1 %os E% 6 o carrier fre>uency C H s!eed of sound )*F0 mLsec [ H angle of incidence -y factor 2 is in e>uationD Some say it accounts for two directions of sound travel H to te moving R3C and .ac: to te receiver 2 tin: it may .e sim!lier tan tatC Cos is not linear" error inreases wit greater angleC o Cos 0 , ) o Cos E0 H 0&8G o Cos F* H 0&+0 o Cos G0 H 0&* o Cos %0 H 0 So if you :ee! angle at G0" cos of 0 is 0&*" ence multi!lying it .y 2 will yield error factor of ) i&e& no errorM o 2 degree angle error 2f confuse *8 degrees wit G0 , 'SV assessment is GO off 2f confuse +8 degrees wit 80 H 'SV assessment is )+O off 13. (on)in*asi*e testing o*er*iew: Bsta.lis clinical indication first Use to !lan angiogra!y or survey graftsL:nown stenosis Start wit resting A32 and 'VR& o 2f tese are a.normal may order targeted arterial du!le/ to see waveforms and velocities o 2f A32 are normal .ut clinically sus!ect claudication Order stress testingLy!eremia 14.Doppler wa*e for!s: o 'ulse contour H Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )% Canadian Vascular Surgery Minimum normal H tri or .i !asic 6rist wave H !rograde energy from te cardiac out!ut" 2 nd wave H reflection from te !eri!eral resistance" E rd wave H reflection is overcome .y te last :ic: of te !rograde effect of systolic flow& Velocity increases ra!idly in early systole" reaces !ea:" ten dro!s off" reversing in early diastole& 2n late diastole" velocity tracing .ecomes !ositive .efore returning to te ;ero,flow .aseline& -it increasing vasoconstriction" te reverse,flow com!onent .ecomes e/aggerated& o Same seen wit microem.oliM -it decreased resistance" reversed !ase may disa!!ear H wave .ecomes .i!asic o seen normally in renal" celiac" fed state SMA and cere.ral circulation
A.normal !atternH wit !ro/imal stenosis 3lunt slow u!stro:e ) st !ase dro!s 2 rd !ase ten E nd stage disa!!ears 'ea: !ulsatility inde/ goes downM Mono!asic waveformC .lunted wit slow u!stro:e and !rolonged um! tracing more continuous and less !ulsatile& o S!ectral analysis H summari;es and descri.es availa.le range of vector velocities in te vessel& 5e more te tur.ulence" , te more direction and velocity cange and te .roader te s!ectrum& Aoo: for te disa!!earance of te clear window under te tracing o 'resence of reverse flow com!onent is igly !redictive of intact inflow o A.sence of reverse flow may .e related to oter factorsC Aow resistance" y!eremia" vasodilators mono!asic wave due to severe inflow disease& B/aggerated 2 nd com!onent H increased outflow resistance 0microem.olism1 ?ence te following means are availa.le to analy;e waveformsC .ea= (o .ea= 5u+sa(i+i($ inde7 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 20 Canadian Vascular Surgery Minimum o '5' fre>uency difference of te #o!!ler waveform divided .y te mean fre>uency i&e& !ea: of systolic first wave P !ea: of te reflected 02 nd 1 wave in early diastoli of te same cycle NO5 !ea: to !ea: of two different cycles o 2n normal lim.s" '5' increases from !ro/imal to distal 3ecause MBAN !ressure dro!s in !eri!ery o 'rovides good descri!tion of !ro/imal inflow lesionC i&e& first wave is .luntedLdecelerated and reversed wave is reduced o -it !ro/imal stenosis" tis increase from !ro/imal to distal is not seen o B&g& NormalC C6A )E ,Q distal )8 Aortoiliac occlusion 2,QF S6A occlusion G,QF .ot E,QE 'ressure 'ulsatility inde/ H if Q F in C6A H li:ely rules out aortoiliac disease o A.normal value H inter!ret wit caution Aa!lace wafeform transformation 'ower fre>uence s!ectrum analysis 'ulse transit time 5ese evaluate lesion indirectlyM 'referred metod is direct e/amination of te lesion wit 3,modeLwave form analysis& )*& Critical stenosis + residual radius and surface area of t"e lu!en: 5e cange in energy content of te flow is a function of radius of te vessel raised to te F t !ower AN# velocity of te fluid& o 'oiseuelle9s e>uation 2nitially" wit small reduction of radius" te energy 0!ressure1 loss is small" owever !ressure dro!s e/!onentially wen critical radius reduction is reaced o *0O radius or +*O surface area o 3ot due to velocity cange AN# radius cange At tis critical !oint" 'ressure dro!s !reci!itously H i&e& critical stenosis is reaced& 2n sim!le terms" narrowing at wic !ressure and flow .egin to .e affected& #oes not a!!en until *0O diameter reduction is reaced o e>uivalent of cross,sectional area of +*O Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2) Canadian Vascular Surgery Minimum 16.Resting A,I + ad*antages and disada*antages: o Advantages of resting A32C Suic:" easy" cea! B/cellent 'rognostic survival info 06ramingam study1 Re!roduci.le Can .e used to follow and assess effect of t/ 0min 0&)* cange is clinically sig1 o Aimitations of resting A32C #oes not locali;e occlusive disease !recisely #oesn9t measure internal iliac and !rofunda 0i&e& non,a/ial arteries1 #oesn9t detect multilevel disease #oesn9t relia.ly !redict !ro.a.ility of trom.otic e!isode in graftL'5A site #oesn9t detect occlusion distal to an:le Unless measure 5oe 3racial 2nde/ artificial elevation in calcified vessels Renal 6ailure and #M H i&e& false negative is !ossi.le can9t use in large wounds Sources of errorC Cuff si;e 0need to .e at least *0O larger tan lim. diameter1 Aarge collaterals will elevate A32 ?5N and CO variation o A32 is an e/cellent !redictor of CV mortalityC Additional notes on A32C 'ressure difference .etween #' and '5 sould .e less tan )0 mm ?g& Q )* H sus!ect stenosis An:le !ressure Q .racial !ressure .y )2,2F mm o augmented systolic !ressure .ut diastolic is less Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 22 Canadian Vascular Surgery Minimum o mean !ressure is same ow to 2# A32 in calcified dia.etic footC o elevate foot o note disa!!earance of distal #o!!ler signal o multi!ly distance in cm .y 0&+E* A32s o #on9t measure non,a/ial !ressure o #o not distinguis vasos!asm vs stenosis o #o not !ic: u! non,flow limiting lesions in trauma 2n trauma" Q 0&% H no need to angio Additional notes on 'VRC Reflect total volume of te lim. 2deally measure u!!er" lower ting an calf o Normal , Calf am!litude e/ceeds tig am!litude .y 2*O 2f not H sus!ect S6A occlusion o 2naccurate for aortoiliac disease Unless use 2 tig cuffs o Accurate for femoral lesions BVBN wit aorto,iliac disease u!!er tig !ressure o .y cuff, always e/ceed .racial .y E0,F0 cm Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2E Canadian Vascular Surgery Minimum 5ig 3racial inde/ )&E,)&F ?owever" direct 0invasive intraarterial1 !ressure is same as .racial 2f cuff !ressure is same or less H sus!ect significant aortoiliac stenosis 'ressure gradient .etween levels Q E0 mm ?g H suggest o.struction o U!!er tig !ressure 0!rofunda AN# S6A1 vs lower tig !ressure Sould .e same 2f different .y )* mm H S6A disease ?ori;ontal difference Q 20 mm is significant Multilevel disease is difficult to distinguis on 'VR 17. Stress testing and A,I: B/ercise increases cardiac out!ut and flow troug te aortaLiliac system& 2f te velocity is increased 0as seen in stenotic iliac lesion during e/ercise1" te Raynold9s num.er can rise and eventually cross 2000 mar: H turning flow into 5UR3UABN5& 5is translates into energy losses and dro! in !ressures !ast stenosis& Outflow resistance reduction 0due to ma/imum vasodilation1 is designed to counteract tis& ?owever it can9t fully com!ensate for all te energy loss at te stenotic segment& AdvantagesC o Uncovers lesions tat are asym!tomatic at rest !articularly in te iliac system o Allows to esta.lis functional significance of te lesion o Allows com.ined assessment of wal:ing a.ility and restriction im!osed .y orto!edic" neurologic and cardiol!ulmonary disease 'rinci!leC o Normal individuals do not dro! A32 after * min& o Magnitude of dro! reflects degree of o.struction 5ecni>ueC o Su!ine for 20 min" .aseline A32 o 2 m! at )0O incline wal: for * min OR until claudicationLrestriction o Su!ine !osition H remeasure A32 > 2 min until !re,e/ercise value acieved OR 20 min ela!sed& Oter facts on B/ercise testingC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2F Canadian Vascular Surgery Minimum o #o not use in CA2" cardiac cri!!les o 'ost e/ercise H re,measure .racial !ressure H it usually rises" so need to esta.lis new .aseline& o 5e more !ro/imal te o.struction" te greater te effect of e/ercise on an:le !ressure o An:le !ressure R G0 mm !ost e/ercise H test is !ositive o Reactive y!eremiaC Su.stitute for e/ercise E,+ min su!rasystolic !ressure on tig Monitor an:le !ressure at )* sec ten E0 sec interval Normal res!onse H initially dro!s to 80O .ut comes .ac: to %0O witin E0,G0 sec& 5oe !ressures o Assessment of functional severity o Sows degree of ma/imal dilation of !eri!eral .ed o rea!!ear almost immediately" .ut wit 2 fold increase in am!litude& o A.normal H toe !ressure does not come .ac: for Q )20 sec o #irect !ressure and 'a!averin H E0 mg intraarterial H Q 20 mm !ressure dro! significant Surgical sym!atectomy and y!eremia res!onceC o 2f !osty!eremia res!onse H twice !rey!eremia H may .enefit from sym!atectomy Measures an a.ility to dilate in res!onse to a release in vascular tone Not a test of integrity of sym!atetic system Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2* Canadian Vascular Surgery Minimum 5o cec: functionC o 'VR will decrease wit dee! .reat if sym!atetic is intact 18. xtre!ity arterial duplex and stenosis: o No stenosisC !sv R)*0" ratio " )&* o E0,*0O C !sv )*0,200" ratio )&*,2 o *0,+*OC !sv 200,F00" ratio 2,F o Q+*OC !sv QF00" ratio QF o Mono!asic non,continuous staccatoLtum! !ro/imal to stenosis 0no diastolic1 o Mon!asic continuous flow distal to stenosis Artery Normal #iameter in 3 mode Normal 'SV B2A 8 mm )20 cmLsec C6A 8 mm ))* cmLsec 'ro/imal S6A G mm %0 cmLsec #istal S6A *&* mm %2 cmLsec !o!liteal * mm +0 cmLsec Aortoiliac and !eri!eral waveform in stenosis o )00O 'SV ste! u! 0velocity ratio 21 com!ared to normal segment !ro/imally is significant o 3est accuracy H ratio 2&*,E o Color do!!ler witout velocity waveform analysis is !oor at >uantifying stenosis Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2G Canadian Vascular Surgery Minimum 2nflow !ro.lem 0low am!litude" reduced u!stro:e1 Outflow stenosis 0no distal flow" no diastolic flow1 Normal u!!er e/tremity waveform Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2+ Canadian Vascular Surgery Minimum R su.clavian stenosis 19.-enous graft follow up: o RF* cmLsec" no diastolic flow H !redictors of early failure RF* cmLsec .ut normal flow may .e seen in large diameter vein o Surveylance of grafts im!roves !rimary assisted !atency .y 20O o 2ntervene if 'SVQE00" ratio Q E&F 20.%"y does steal after fe!)fe! or ax).ife! occur rarely? 3ecause usually te inflow is NO5 limitedM o -it am!le inflow" .ot receiving .eds receive ade>uate .lood su!!ly o 5ere is increased 0dou.le1 flow in donor artery if outflow is increased o 5e flow is distri.uted to eac e/tremity according to te resistance in eac wic is more or less e>ual under normal resting circumstances Vascular steal arises wen 2 run off .eds wit different resistance are su!!lied .y a +imi(ed sou"%e o' in'+o, o Com!etition arrises o 2f inflow is limited" te run off .ed wit less resistance will ta:e te flow !referentially over te oter .ed rendering it clinically iscemic o -it !resence of 'V#" te overall resistance of diseased lim.s is ig ig segmental resistance" ma/imally dilated outflow .ed resistance tat can9t dro! its resistace more wit e/cercise o ?ence initially iscemic lim. may .e rendered even more iscemic 21.Carotid ultrasound + %as"ington/ (ASC& and CS& criteria o -asington criteria H .ased on BCS5" NO5 NASCB5 angiogra!ic correlation BCS5 H outlines y!otetical normal carotid .ul. and measures stenosis wrt tis NASCB5 H com!are distal 2CA to stenosis May get negative stenosis figures Com!ared to BCS5" !redicts less severe stenosis Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 28 Canadian Vascular Surgery Minimum o Angiogram H underestimates stenosis o MRA !ro.a.ly e>uivalent to du!le/ US o ?ig sensitivity study A.le to recogni;e an a.normality needed for sym!tomatic !ts o ?ig s!ecificity study a.ile to recogni;e normal artery needed for asym!tomatic !ts Washing(on F"i(e"ia o Remem.er tat it OVBRBS52MA5BS te stenosis 0BCS5" not NASCB5 criteria1 o Remem.er" tat it gives ranges tat do NO5 a!!ly for AN= study H i&e& NASCB5 0+0O stenosis 1 and ACAS 0G0O stenosis1 o NormalC no !la>ue" smoot walls" .oundary layer se!aration in .ul. o R )* O mild S3 o )G,F%O mar:ed S3" no systolic window o *0,+%O 'SV Q)2*" '#V R)F0 cmLsec" mar:ed S3" 2CALCCA Q )&8 o 80,%%O 'SV Q)2*" '#V Q )F0 cmLsec" !oststenotic tur.ulence" 2CALCCA Q E&+ o OcclusionC no flow May .e wrong in EO of cases H ence AA-A=S confirm tis wit angio or MR2& 2n measuring carotid velocityC o :ee! gain low H may artificially cause S!ectral 3roadening o :ee! sam!le volume low 0)&* mm1 o notice !ost,stenotic tur.ulence and color flow mosaic 22.(or!al Carotid and -erte.ral flow *elocities: o CCA No defined a.normal 'SV Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2% Canadian Vascular Surgery Minimum Normal flow most of te time R)00 cmLsec 2f #ecreased& 6irst com!are R and A o 2f .ilateral H aortic stenosis or myocardial failure o 2f unilateral CCA origin stenosis H all velocities !ast CCA are dam!ened 2f elevated o ?y!erdynamic state if .ilateral o rLo contralateral CCAL2CA occlusion com!ensatory flow flows increase from arc to CCA .ifurcation %cmLsec !er cm Measure CCA 'SV for ration at a #B62NB# location o Usually F cm .elow .ifurcation o -idt of a trasducer o 2CA H normal velocity *F,88 cmLsec o BCA H normal velocity ++,))* cmLsec No criteria for stenosis Sus!ect stenosis if Q)2* cmLsec and !ost,stenotic tur.ulence See notc wit tem!oral ta! o 2CA and BCA sould AOOI and SOUN# different 2f not" sus!ect 2CA occlusion and confusion of .ranc of BCA for 2CAM o Normal verte.ral flow RG0 cmLsec Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age E0 Canadian Vascular Surgery Minimum 2ncreased flow seen in #ominant verte.ral 0MC on te A1 Near occlusion of 2CA 23.Consensus panel on 0S criteria on stenosis: o 5ese are more !ractical ten -asington H .ased on Nascet tecni>ue and range of measurements of stenosisC o R*0O 'SVR)2* B#VRF0 Ratio R2 o *0,G% 'SV )2*,2E0 Visuali;ed !la>ue B#V F0,)00 Ratio 2,F o Q+0 'SV Q 2E0 Visi.le !la>ue B#V Q )00 Ratio QF Aside notes on A.normal velocitiesC 6alse elevation in 2CA 'SV C Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age E) Canadian Vascular Surgery Minimum o Contralateral occlusion o ?y!erdynamic state o 3ad angle o 'ost stent or endarterectomy 'SV in carotid stentC o Q)*0 cmLsec is NO5 Q*0O stenosis o 'svQE00 and B#V Q )F0 H !redicts ig grade stenosis .ut need angio to confirm Carotid occlusion o -aterammer waveform 0sar! u! and .elow ;ero line downstro:e" no diastolic flow o Acute trom.us o No flow in 2CA o 2n imagingC Use !ower #o!!ler 2f !ulsedC Iee! '6R low to detect low flows 2ncrease #o!!ler gain to 2# slow velocity 2nnominate stenosisC o #ecreased CCA wave o Reversal of flow in 2CA and CCA Croucing .unny waveform o Carotid steal can only a!!en on R side See reduced 'SV in 2CA" reversal of flow in diastoli Aong severe stenosis in 2CA will ave reduced 'SVs" not eleavated&&& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age E2 Canadian Vascular Surgery Minimum o ?ence always rely on ratio 2CALCCA in tese cases& o Ma:e sure CCA is not elevated 0i&e& Q)00 H due to cLl occlusion 24.Ot"er useful *elocities !easure!ent for carotids
o QG0O stenosis H e/ternal Oregon validation wit angio 'SV Q2G0" B#V Q+0" ratio Q E&2& Accuracy %0O o NASCB5 Q +0O stenosis 'SV Q280" B#V Q 80" Ratio QF ''V %*O o Q80O stenosis 'SV Q2*0" ratio QF %0O accuracy for +0,%%O range o 2ntrao! du!le/ assessment of CBA Re!air if 'SVQ200 o Su.clavian artery stenosis Retrograde 0notced1 verte.ral flow o No graded 'SVs values vs occlusion for verte.ral artery flows o Verte.ral stealC See eiter reversal of flow or stalled flow 're,steal , 3ac: 0systoly1 and fort 0diastoly1 #on9t confuse wit !asic flow in verte.ral vein Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age EE Canadian Vascular Surgery Minimum 25.1re2uency of Sur*eylence of known stenosis o Asym!tomatic Q G0 stenosisO 2f 'SVR)+* cmLsec 'rogression is FO over 2) monts 2mage annually 2f 'SV Q )+*O 'rogression 2GO over )F monts ?ence image > G mont 26.&ranscranial Doppler o Color flow" 3,mode" !ulsed #o!!ler o 2ndications Bvaluate cere.ral vasos!asm 0!ost SA?1 3u..le study 0for !atent foramen ovale1 Screening cildren wit sic:le cell disease 02 don9t :now wat tat means1 D inrao! monitoring and assessement for sunt need Dearly diagnosis of y!er!erfusion syndrome Need to :now MCA flow !reo! 2f see 2 fold increase in mean velocity H ave your diagnosis Not cost effective to 4ustify routine use 5ere is NO indication for 5C# in routine carotid US o ?ow to doC 2 M?; Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age EF Canadian Vascular Surgery Minimum 5ranstem!oral window and su.occi!ital window 2# MCA" ACA" ')" '2 Ket mean 0not angled corrected1 velocity H assume 0 degrees correction NUE0,80 Vasos!asm Q )20 o 6or R'V2 e/am" you ha&e (o =no, wat arteries are sam!led in wic window and te direction of flow in tese areteries H away or toward te transducer Ai:e" you are going to need to use tis in real lifeM 27. Renal artery 0S o #o clinical !rofiling first Atero , Q*0yoa" R6" ?5N 6M# H young female wit ?5N o Overnigt fast o Aongitudinal view of su!raceliac artery first Convert to transvers 2# A renal vein 2# origin of .ot renal aa& 2mageC Orifice 'ro/imal Mid #istal 2nterlo.ar and arcuate flowsC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age E* Canadian Vascular Surgery Minimum o U!!er !ole o Mid !ole o Aower !ole Measure :idney si;e o Com!are si;e" Q )&* cm difference significant o R % cm !ole to !ole suggest atro!y o 2ndirect measurements of flowC i&e& measure random artery in !arencyma NO5 !ros!ectively validated Resistive inde/C 0),B#VL'SV1 2f Q*O .Ll difference" diagnose *0O stenosis Not wor: if .ilateral disease R2 R0&8 %GO sensitive *EO s!ecific 5o !redict im!rovement in renal failure !ost stenosis re!air R2 Q 0&+* AN# B#V R%0 May get reduction of *PL,* mm ?g !ressure Ai:ely NO clinical .enefit 5RANS'AAN5B# :idney R2 Q 0&8 o ''V 88O" N'V %EO to !redict deat" need for dialysis and Cr clearance deterioration o Normal flow H low resistance" 'SV R)80 cmLsec o Stenosis Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age EG Canadian Vascular Surgery Minimum RAR Q E&* , G0O stenosis 8FO sensitivity %+O s!ecificity ''V %FO 'ros!ectively validated 'SV Q200 cmLsec , G0O 3ut wit RAR is MORB !redictive H i&e& can diagnose G0 O stenosis if RARQE&* regardless of 'SV value o #u!!le/ of renal artery H CAN95 see accessory arteries o Renal artery aneurysmC Associtated wit Vasculitis 6M# #issection macroaneurysm 28.#esenteric duplex o Screen for CM2 o G fast 6astingC Aow flow" ig resistance 6edC ig flow low resistance o 2,F M?;" su./i!oid and R lateral 0liver window1 o SMA 'SV 2+* cmLsec H +0,)00O stenosis B#V ** cmLsec , Q *0O stenosis o Celiac Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age E+ Canadian Vascular Surgery Minimum ?ig flow" low resistance all te time 'SV Q200 cmLsec B#V Q** cmLsec Retrograde flow in C?A if celica is stenosedLoccluded #ifficult to assess flow in celic if SMA disease is !resent -it median arcuate syndrome" 'SV goes u! wit BJ'2ration" normali;es wit ins!iration& o C?A Normal 'SV G0,)2* Aow resistance o 'ortal vein 2n fasting state H 'SV 8,)8 o Varies +0,)00O in si;e wit res!iration o Kradient wit 2VC *,+ mm o 'ortal y!ertension Si;e Q)E cm Slow flow 6low away from liver 0e!atofugal1 2n N" sould see same direction of flow in C?A 29. 0S and -AR o Most of te time useless H difficult to get good !ictures o Bndolea: ty!e 2 2f R80cmLsec, li:ely to trom.ose 2f Q)00 cmLsec unli:ely to trom.ose Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age E8 Canadian Vascular Surgery Minimum 30.0ltrasound of Transplant: o Aiver ?e!atic artery stenosis #ifficult to get true angle 'SV 'arvus tardus most common finding in stenosis o A5 Q0&0E" R2 is less tan one 5rom.osis H emergent e/!loration 0.ile ducts de!end on it1 ?e!atic artery s!asmC ?ig resistive flow Reduced 'SV" no flow in diastoly" may .e reversed flow R2 is )&0 o IidneyC Renal a& stenosis H 'SV Q200" renal H iliac ratio Q )&8 On intrarenal s!ot testing H tardus !arvus H A5 Q0&) Blevated R2 Renal VB2N trom.osis 6luid collection O.struction Re4ection A5N #rug ne!roto/icity 2ntrarenal AV6 'ost .io!sy Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age E% Canadian Vascular Surgery Minimum Rare cause of iscemia" may cause tn 31.0ltrasound and c"ronic *enous insufficiency o #u!le/ assessment rLo #V5 assess outflow augmentation studies dee! and su!erficial flows" !erforators reflu/C lying and standing !lus cuff rLo AVM o AV' Am.ulatory venous !ressure Venous !ressure measured directly in dorsal vein after )0 di!,toes 0)Lsec1 Calf contractions increase outflow o Strain gauge 'letysmogra!y Used for #V5 Not anymore Assess .aseline value Measure increase in volume after calf contractions N 2,EO cange a.ove 2f outflow !atology H see R 2O volume reduction o 2m!edance !letysmogra!y 6or #V5 Not used anymore Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age F0 Canadian Vascular Surgery Minimum 32. C"aracteristics of *enous flow: o 'asic 2f continuous H sus!ect !ro/imal o.struction OR collaterals from !rior #V5 2f !ulsatile H sus!ect R?6" fluid overload" AV6 2n u!!er e/tremity" it is NORMAA to e/!ect to see some !ulsatile flow .ecause of !ro/imity to te eart& 'ulsatility is A3normal in leg veins o Unidirectional o Res!onds to Res!iration Valsalva Com!etent valves Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age F) Canadian Vascular Surgery Minimum 2ncom!etent vein AV6 in leg veinC !ulsatile flow Continuous flow H outflow o.struction 33. 0ltrasound and Dialysis access o Normal graft velocities 'sv )*0,E00 Bdv G0,200 Mar:ed s!ectral .roadenings critical velocity in dialysis graft 'SV R)*0 cmLsec normal flowC o Q800 ccLmin o early stenosis *00,800 ccLmn o severe stenosis R*00 ccLmin Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age F2 Canadian Vascular Surgery Minimum A&HROSC$ROSIS 3 RIS4 1AC&ORS5 &6: 34.P"ysiologic role of endot"eliu! : o Normal endotelium functionC Modulator of coagulation system ?e!arin" t'A" trom.omodulin 'ermea.ility .arrier for nutrients<fluids Ai!ids" glucose" water 'ermea.ility .arrier to cells Regulates inflammatory res!onse Normally Nonaderent surface for !!tLneutro!ils o Regulated .y 2CAM" VCAM rece!tor e/!ression 2ni.it SMC !roliferation witin intima o 5K6. H transforming K6 angiogenesis modulation VKB6 to grow new vessels Vascular tone modulation NO < !rostacyclin vs endotelin < angiotensin o Bndotelial !roductsC B#R6 0NO1 < 'rostocyclin , dilating Angiotensin and endotelein H constricting 5!a" e!arin" trom.omodulin o -at damages endotelium Mecanical < low Seer stress Meta.olic stress H e/cess of A#A" glucose 2mmunologic stress , infection Vasoconstrictor stress smo:ing 35.1actors i!portant for at"erosclerotic pla2ue de*elop!ent: o Sear stress o 6low se!aration and stasis o 5ur.ulence and Oscillation of sear stress vectors o ?y!ertension and ?eart rate 5ese contri.ute to tur.ulence and seer low ?R , less aterosclerosis in carotids ig ?R H less ateroscleosis in infrarenal aorta o structural disorders H !seudo/antoma elasticum Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age FE Canadian Vascular Surgery Minimum o vasa,vasorum o.literation < fi.rosis H due to radiation 36.Role of !acrop"ages in at"erosclerosis/ list !acrop"age secreted 71: o 2n4uredLaltered endotelium e/!oses adesion molecules tat attracts monocytes o Monocytes migrate into su.endotelial s!ace and turn into macro!ages o M'? !ic: u! o/idi;ed A#A H turn into foam cells o 5is u!ta:e causes M6 to syntesi;e Monocyte colony stimulating factor 0M,CS61 Kranulocyte colony stimulating factor 0K,CS61 e!idermal K6 0BK61 !latelet derived K6 0'#K61 transforming K6 al!aL.eta Vascular endotelial K6 0VBK61 monocyte cemoattractant !rotein ) 0MC' )1 o more monocytes are attracted" !la>ue starts to remodel 37.%"at "appens in at"erosclerosis: o 'rimarily an BN#O5?BA2AA disease tat s!ills over to te media o Bndotelial in4ury OR alterered !ermea.ility to li!o!roteins first o more adesive molecules formed 2CAM" 'BCAM H !!t and -3C movement into vessel wall o cyto:ine !roduction .y endoteliumC '#K6" 6K6R 5K6." 2A ) local cells 0SMC1 and new arrivals 0monocytes1 are transformed and caused to !roliferateLmove to intima monocytes form mast cells ,Qfoam cells o li!id accumulation in foam cells" wic later s!ills outside to te media < around SMC o li!id core is formed under endotelium o collagen and connective tissue is formed ,Qfi.rous !la>ue o !la>ue can ru!ture , Q leading to luminal trom.osis and ateroem.olism 38.Stages in at"erosclerosis and types of pla2ues: )& 2solated 6oam cells a& transformed monocytes,Qmacro!ages wit li!id 2& fatty strea: 0collection of foam cells1 E& fat accumulation outside of foam cells a& li!id dro!lets 3B5-BBN SMC distorting teir arrangement in media Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age FF Canadian Vascular Surgery Minimum F& formed li!id core in 2N52MA *& toug fi.rous ca! G& ru!tured ca!Lcom!le/ ateroma 39.(a!e different !ediators secreted .y endot"eliu!: o 'rocoagulant H !lasmingen activator ini.itor 0'A21" von,-ille.rant 6actor o Anticoagulant H e!arin" trom.omodulin" t'A o Vasodilator H !rostacyclin" NO 'rostocyclin also increases cAM' 0reduces !lt aggregation1 o Vasos!asm mediator H angiotensin 2" endotelin 40. ndot"elial progenitor cells: 6ound in circulation Released .y 3M in res!onse to iscemia and trauma Ca!a.le of endotelial re!air" serete t'A #ecreased in !t wit cardiovascular disease and smo:ers 'resent in .ot young and old 41.#ec"anis! of action of (itric oxide/ or ndot"elial Deri*ed Relaxing 1actor: o Smoot muscle rela/ant o 2ni.its !!t and -3C aggregation 42.ffects of s!oking: ?istologically" smo:ing damages endotelial cellC o swelling" Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age F* Canadian Vascular Surgery Minimum o .le. formation" o su.endotelial edema" o tic:ening of .asement mem.rane" o widening of endotetelial 4unctions& increases viscocity and decreases o/ygen trans!ortC o car.o/y?K due to CO wic leads to increase in ematocrit o aggregation of -3C and !tt o fi.rinogen content in .lood increases 5ese events lead toC o 2ncreased trom.ogenicity #ue to increased viscosity due to increased ematocrit #ue to decreased fi.rinolytic ca!a.ilityLincreased fi.rinogen #ue to direct endotelial in4ury and vasos!asm o due to decreased NO !roduction o due to increased !latelet aggregation o Altered Ai!id meta.olism H decreases ?#A" u!ta:e of A#A increases o Reduced o/ygen deliveryC #ue to increased car.on mono/ide SummaryC Affects AAA functions of endotelium 2ncreases trom.ogenicity o 2ncreases viscocity of .lood o 2ncreases fi.rinogen #ecreases o/ygen delivery 0car.on mono/ide effect on ?g1 Affects li!id meta.olism o A#A u!" ?#A down 43.#ec"anis! of action of Angiotensin II: o Vasoconstrictor o 2nduces inflammatory cyto:ine 2A G o Releases aldosterone o Releases A#? o 2ncreases sym!atetic tone o Vessel and myocardial wall y!ertro!y Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age FG Canadian Vascular Surgery Minimum 44. ACI effects: o MecanismC ini.its conversion of A5 2 to A5 22 u!regulates .rady:inin H o causes coug and vasodilation ini.its aldosterone ini.its A#? increases AV contractility remodels myocardium and vessels A#A o/ygenation reduction numerous !leotro!ic effects on endotelium 0SMC ini.ition" NO induction" !!t adesion ini.ition1 )GERALL EDDEFT;- TR9..ED )HT an(ih$5e"(ensi&e
o Reduces ris: of M2" CVA" deat due to CV cause 0?O'B1 o 2n acute M2C decreases deat" !rogression to C?6 and need for os!itali;ation due to C?6 0A2RB1 o Com!ared to oter anti y!ertensive meds" in dia.etic !ts ave 3B55BR !revention of !roteinuria" ne!ro!aty !rogression" !reservation of renal function" control of ?5N& o ContraindicationsC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age F+ Canadian Vascular Surgery Minimum :nown y!ersensitivity life treatening angioedema 5"egnan%$ 6(e"a(ogeni%# bi+a(e"a+ RA; or sole :idney RAS 0A5 22 is needed to maintain K6R H ACB2 will cause acute R61 aortic stenosis ?y!ertro!ic Cardiomyo!aty H ris: of y!otension from fi/ed outlet o.struction 45. %"at are t"e effects of statins? Colesterol lowering , reduce A#A and im!rove ?#A 'leotro!ic effects H BJ5RBMBA= im!ortantC o 'ositive effects seen in !eo!le wit NORMAA colesterol o Sta.ili;e !la>ue o Reduce macro!age activity in te !la>ue o Cause !la>ue fi.rosis Ru!ture !rone 0ecolucent" li!id laden1 transform into toug sta.le !la>ue 0eogenic" fi.rous1 o Nutritive effect on endotelium tat canges !rocagulantLanticoagulant !ro!erties of endotelium Reduce venout trom.oem.olism Sta.ili;e AAA and reduce teir growt 0yes" sir1 Overall" reduce stro:e" reduce CV mortality& 46. 8upiter trial/ 9::;: 'ts wit normal li!id !rofile .ut ig CR' Males Q *0 yoa" females Q G0 yoa" NO istory of #M" CVA" M2 )+"000 !ts randomi;ed to !lace.o vs 20 mg of rosuvastatin At 2 years trial sto!!ed 2m!ressive reduction inC o in te various com.ined end!oints" wic included stro:e" eart attac:" angina" and .y!ass surgery 0FFO1& o com.ined end!oints of stro:e" myocardial infarction" and cardiovascular deat 0F+O1 as well as a o reduction in total mortality 020O1& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age F8 Canadian Vascular Surgery Minimum 47.%"at !ec"anical factors can in<ure endot"eliu!? o Bm.olectomy cat o '5ALwire o Bndarterectomy o Valvulotomy o Overdistension of vein graft o Anastomosis construction 48.Steps in inti!al "yperplasia de*elop!ent: o Bndotelial in4ury o Coverage of denuded area .y car!et of !latelets o '!ts release K6 '#K6" BK6" 6K6 o Krowt factors stimulate endotelial AN# smoot muscle cell !roliferation o 'latelets are dis!laced .y neo,endotelium o Medial SMC !roliferation caused .y !latelet K6 o ;MF mig"a(ion a%"oss in(e"na+ e+as(i% memb"ane in(o in(ima o Iene"a(ion o' e7"a%e++u+a" ma("i7 b$ ;MF in ini(ima Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age F% Canadian Vascular Surgery Minimum 2n te end" luminal diameter is decreasedM 49. How can inti!al "yperplasia .e pre*ented=treated? o Anti!latelet agents H ini.it !latelets , mediators of y!er!lasia ASA" K' 223222A" !lavi/ o Seeding of grafts wit endotelium H e/!erimental" only !ro/ and distal ends of te syntetic graft are seeded& o 2ni.it SMCC #rugs H sirolimus" tacrolimus Aocal irradiation Nitric o/ide Kene tera!y o 6urter surgical reconstructionC animal studies suggest tat 2? is self, limiting , on%e %om5+e(e, "ene,a+ o" %on(inued h$5e"5+asia is un+i=e+$ 2 hen%e su"gi%a+ "e%ons("u%(ion o' s(enosed g"a'( is 'easib+e8 50.How can R1 for at"erosclerosis .e !odified: o #M control H diet" e/ercise" medication" weigt loss" foot care Reduces M2Ldeat due to vascular causes UNCABAR if it !revents !rogression of ulcers" No eveidence it !revents am!utations or infections o ?5N H diet" e/ercise" medication decreases o all cause mortality .y )2O" o stro:e mortality .y EGO" o coronary mortality .y 2*O o #isli!idemia H diet" e/ercise" medication" weigt loss sta.ili;e !la>ue and !rogression of 'A# o F0O reduction in !rogression of 2C for every )0O reduction of total colesterol" )*O reduction in mortality im!roved !atency of infrainguinal .y!ass o Smo:ing H cessation !rogram" drugs" su!!ort grou!s alt claudication ,Q rest !ain !rogression im!roves !atency of revasculari;ation !rocedures im!roves survival no evidence it im!roves sym!toms of 2C o y!eromocysteinemia H .y diet and folate im!act un:nown yet Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age *0 Canadian Vascular Surgery Minimum 51.&arget for lipids: 2deally A#A R E mmol ?#A Q ) mmol ?owever" if ris: for CA# low H A#A R * mmol" 5CL?#A R G moderate H A#A RE&* mmol" 5CL?#A R * ig H A#A R2 mmol" 5CL?#A RF 2f ave #M H A#A R 2 mmol 52.PAD and risk reduction: o Aife style modificationC -eigt loss B/ercise Cease smo:ing Control ?5N Control Ai!ids Control #M o S!ecific #rugsC 'latelet ini.itorsC ASA" COJ ini.itor" o limits !roduction of trom.o/ane A2 o inflammation" !latelets9 aggregation and vasoconstriction is limited o 'latelets are affected irreversi.ly o endotelium >uic:ly regenerates !rostacyclin secretion is restored& 5is a!!ens wit low dose ASA H B/!lains .etter small dose effectiveness com!ared to a large dose& o given !erio!" see reduction of CA3K failure .y )0O Clo!idogrelL!lavi/LticlidC o A#' rece!tor ini.itor o 'revents activation of K'22.L222 a com!le/ An A#' de!endent !rocess o A#'LcollagenL!latelet activating factor 0'A61< adenosine induced !!t aggregation is limited K' 22.L222a rece!tor ini.itor H o used !ost cardiac stents" o ini.it .inding of fi.rinogenLv-6 to te a.ove named rece!tor o !ossi.le anti SMC effect Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age *) Canadian Vascular Surgery Minimum vasodilatorsC cilosta;ole" )00 mg .id" !os!odiesterase ini.itor" o increases cAM' in !!ts o reduces !!t aggregation o increases SMC rela/ation& C2 in C?6& SLeC nLv" diarrea" ras" di;;iness" !al!itations reologicC !ento/ifylline H o )200 mg od" o increases R3C deforma.ility and decrease for viscosity& o 20O im!rovement in claud distance in some studies over GL)2& sLeC nLvLdi;;iness ACB2 VesselC o #ilates 0troug NO1 o Remodels 0SMC effect1 'latelets o Reduces aggregation Ai!id o #ecreases A#A o/ygenation Renal !rotection Controls ?5N 0anti aldosterone and A#? effect1 StatinsC VesselC o Remodels via effect on SMC !roliferation and migration ini.ition o 2m!roves endotelium function 'lateletes o Reduces aggregation Ai!id o Reduces colesterol o Reduces A#A o/idation and u!ta:e Reduces insulin 2ncreases fi.rinolysis\ AS2#BC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age *2 Canadian Vascular Surgery Minimum Osler notesM Ro+e o' an(i5+a(e+e(s, s(a(ins and AFE inhibi(o"s in (he managemen( o' 5a(ien(s ,i(h 5e"i5he"a+ a"(e"ia+ disease& tt!CLLves&sage!u.&comLcgiLre!rintLF0LFLE)2 , v& useful article !lus 5ASC Anti!latelet tera!yC inactivate !latelets tus lowering trom.otic com!lications of 'V# associated wit ulcerated !la>ue ru!ture& May ave .enefit in maintaining !atency of !rostetic grafts& BvidenceC 2n !ts wit 'A# !articularly as it was sown to decrease overall reduction in cardiovascular events& 5is was initially demonstrated in !ts wit 'A# and coe/isting CA# and Cere.ral arteries #isease 0Antitrom.otic 5rialist9s colla.oration 02*O reduction in CV events1N and later confirmed for all su.grou!s of !ts wit 'A# 02EO odds reduction1& Com!ared to ASA" Clo!idogrel offers 2FO .etter ris: reduction in CV events in sym!tomatic !ts wit 'A# 0a.solute RR is only )&2O1& Com.ination of ASALclo!idogrel is re>uired !ost S6A stent insertion to reduce ris: !osto!erative instent trom.osis& Anti!latelet medications ave .eneficial effect on !atency of !rostetic lower e/tremity .y!ass graftsC RR of occlusion wile on te ASA tera!y is 0&+8 5e CA'R2B trial e/amined te relative safety and efficacy of daily doses of +* mg clo!idogrel vs E2* mg ASA in nearly 20"000 !atients wit iscemic stro:e" M2" or 'A#&5e results of te trial sowed tat clo!idogrel was more effective tan ASA in !reventing te !rimary study end !oint" a com!osite of iscemic stro:e" M2" or vascular deat& 5e trialists found a significant 8&+O relative,ris: reduction 0P U &0FE1 for clo!idogrel over ASA& 'ost oc analyses of te CA'R2B trial ave sown tat certain su.grou!s of !atients wit ig stro:e ris:" including tose wit dia.etes mellitus"tose wit !rior cardiac surgery" tose receiving concomitant li!id,lowering tera!y" and tose wit a istory of more tan ) iscemic event" received significant advantage from clo!idogrel over ASA& 6or e/am!le" in te su.set of CA'R2B !atients wit dia.etes" annual event rates for te Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age *E Canadian Vascular Surgery Minimum com!osite of vascular deat" M2" stro:e" or reos!itali;ation for iscemia or .leeding were elevated com!ared wit te rate in nondia.etic !atients" corres!onding to an am!lified .enefit of clo!idogrel over ASA in tese ig,ris: !atients 02) vs % events !revented !er )000 !atient,years for tis end !oint1& StatinsC tey lower A#A" 5K" A'0a1 H factors involved in !atogenesis of aterosclerosis& Also" tere is evidence tey modulate arterial wall inflammation" !la>ue sta.ili;ation" endotelial dysfunction"
and trom.osis" reduce fasting insulin concentration& BvidenceC ?eart !rotective study demonstrated tat F0 mg of simvastatin at * year fLu in !ts wit 'A# resulted in )2O reduction of total mortality" )+O reduction in vascular mortality" and 2FO reduction in CA#& 5ese findings led to recommendation to lower A#A to R2&*% mmolLA& ) mmolLl reduction in A#A is associated wit 20O RR in ma4or CV events H regardless of te .aseline li!id level 0i&e& including normal range1 and only de!ended on te .aseline assessment of CV ris:" wit 'A# !ts .eing at ig end of te s!ectrum& ACB2 and A5R3C useful ad4unct to 3' management" !articularly in !ts wit dia.etes and 'V#& Moreover" it ACB2 and A5R3 were sown to effect remodeling of te myocardium and vessel wallC tey sare similar to statins !leotro!ic effect on arterial wall& BvidenceC ?O'B study demonstrated 22O reduction in CV events in !atients on rami!ril" inde!endent of te .lood !ressure lowering effects& 5ey ave numerous !leotro!ic effects on te arterial wall ini.ing SMC migration and !roliferation" o/idation of A#A" !latelet ini.ition" stimulation of NO secretion& 53.Conser*ati*e !easures of treat!ent of claudication: Most effective H wal:ing o Bndotelial function o!timi;ation o Alters muscle meta.olism 0anaero.ic training1 o Re,trains to use more !ro/imal muscles o Collateral develo!ment H unli:elyM& o 2m!roves meta.olism of li!ids and glucose #rugs H cilasta;ole" !ento/y!ylline 0!lace.oD1 Smo:ing" R6 H no clear evidence tat it will reverse claudication" .ut will control !rogression of aterosclerosis and !ossi.le conversion to claudication& o ))O of smo:ers wit 2C will undergo am!utation" com!ared to 0O in non,smo:ers o E fold iger ris: of needing intervention if !t as F0 !ac: year of Smo:ing o Cessation will im!rove !atency of .y!ass E foldM Statins H will alt !rogression to CA2 .ut won9t el! sym!toms of 2C Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age *F Canadian Vascular Surgery Minimum o F0O reduction in !rogression to CA2 54.DD of claudication: o Aterosclerosis o Non,aterosclerotic disease Coarctation Bntra!ment Adventitial cystic disease 'ersistent sciatic a 6M# of B2A 'seudo/antoma elasticum Bndotelial fi.rosis of cyclists o mimic:ers Venous claudication Cronic com!artement syndrome 'eri!eral nerve !ain S!inal cord com!ression 0OA1 OA i! 55.Risk factors and !arker of increased risk for P-D: R6C ?5N ?A #M Smo:ing ?omocyseinemia Mar:ers CA# 'revious 'V# events Sedentary lifestyle 6i.rionogen O.esity 6am / 2nflammatory mediators !& )8%+ 56.%"at en>y!atic deficiency is found in "yper"o!ocysteine!ia? o ?omocystein" !roduct of metionine o E en;ymes cystatione 3, syntetase 0C3S1 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age ** Canadian Vascular Surgery Minimum omocysteine metyl transferase 0?M51 metylene tetraydrofolate reductase 0M5?6R1 o omocystein is not fully meta.oli;ed UQ !artial meta.olites accumulate o omocysteine tiolactone 0?5A1 accumulates to/ic to endotelium canges luminal carge causes cellular aggregation accelerates aterosclerosis 0A#A meta.olism1 o treatment folic acid vit 3G" )2" Coline" 3etain o tese el! to meta.olise ?5A folic acid treatment" owever" did not demonstate any effect on CV mortalityM SYMPATHECTOMY 57.How does sy!pat"ecto!y work? o 2ncrease in .lood flow #ro! in resting vasomotor tone Most of increase is non,nutritive" via AV sunting #iminises after * days 0* t day !enomenon1 resting vasomotor tone returns to normal in G mont o Collateral flow increaseC Average ))O increase in flow in animal models o Alteration in !ain !erce!tion Bffective for rest !ain Central and !eri!eral signal conduction attenuation Overall , .etween ealing su!erficial ulcer and relief of rest !ain" sym!atectomy is more li:ely to el! R'C o needs less increase in .lood flow to relieve rest !ain com!aired re>uirements for ulcer ealing o effective !ain im!ulse conduction interru!tion < attenuation 58.Indications for $ower extre!ity sy!pat"ecto!y: y!erydrosis Com!le/ regional !ain syndrome AB vasos!asm , Raynaude9s #2SBASB o Rare indication .ut res!onds very well 'V#C Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age *G Canadian Vascular Surgery Minimum o 2scemic rest !ainC criteriaM& A32 Q 0&E A.sent neuro!aty Aimited tissue loss o 2scemic ulcerationC criteriaM A32 Q0&E Sallow ulcers" non,infected -ill eal in EEO" .ut won9t !revent am!utation o As an ad4unct to Arterial reconstruction 'articulary if small vessel anastomosis is involved #e/tran F0 infusion may .e 4ust as effective for !erioo! !revention of trom.osis of difficult distal anastomosis& May not im!rove long term !atency of .y!ass 5ecni>ueC o Retro!eritoneal dissection o 2# !soas muscle o Cain lies over transverse !rocess medial to !soas m& On te R H under 2VC edge" on te A H lateral to aorta Remove ONA= A2 ,E 2f remove A) H retrograde e4aculation AF does noting Com!licationsC o 'ost sym!atectomy neuralgia Seen in *0OX Anterolateral tig ace -orse at nigt" unaffected .y activity Koes away in )2 monts o Ken,fem n& in4ury o Male se/ual dysfunctionC Retrograde e4aculation 2f .ilateral A) sym!atectomy H 2*,*0O o 6ailure to acieve ade>uate levels of !ain control 59.$u!.ar sy!pat"ecto!y: outco!e ? o B/cellent outcome e/!ected inC Com!le/ regional !ain syndrome y!erydrosis o goodLfair outcome e/!ected inC Raynodes ?owever" res!onse is transient M 3uerger9s disease Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age *+ Canadian Vascular Surgery Minimum Non,.y!assa.le aterosclerotic occlusion wit limited tissue loss o 'oor outcome seen inC Claudicants #M neuro!aty 60.0pper extre!ity sy!pat"ecto!y: 2ndicationsC ?y!erydrosis CR'S Raynauds disease 0ig recurrence1 ?owC )& O!en 0transa/illary , !ainful" !araverte.ral H e/tensive dissection" su!raclavicular H ig incidence of ?orner9s1 2& 5oracosco!icC Colla!se lung Visuali;e ) st F ri.Lverte.ra 2# su.clavian a& H su!erior e/tent of dissection Sym!atetic cain H dorsal" !renicLvagus nerve H ventral Remove all sym!atetic ganglia .elow 5) H i&e& t2 and tE& Aeave stellate ganglion intact H oterwise orner9sC o U!!er !tosis 0Muller9s muscle denervation1 o Aower u!side !tosis o Myosis o PL, enydrosis and loss of cilios!inal refle/ 0nec: !ain H s:in !ric: , causes i!silateral !u!il dilation1 o No 6acial sweating Most common com!licationsC Com!ensatory y!erydrosis 0)00O1 ?orner 0u! to F0O1 2ntercostals neuralgia 0E0O1 'renic nerve is NO5 damaged in toracosco!ic a!!roac& VASCULITIS 61.Raynaud5s: o Syndrome H due to occlusive !atology" may .e unilateral" may lead to ulcers Associated wit C5#" aterosclerosis" y!erviscocity" vi.rational trauma Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age *8 Canadian Vascular Surgery Minimum o %0O , C5# H scleroderma" s4ogren" SAB" RA" myositis On /C rLo 4oint !ain" ras" muscle !ain" systemic s/s" y!otyroidism" re!etitive trauma" frost.ite" 'A#Ls/s of 5OS Aa.wor:C SAB H omogenious ANA Sclreroderma H s!ec:led ANA CRBS5 H anticentromere A3 o Calcinosis" raynauds" eso!ageal dismotility" sclerodactyly" telagectasia o #isease H vasos!astic" .ilateral" no ulcers Btiology is uncertain 'rimary !ro.lem is on BN#O5?BA2AA level o More vasos!astic tan rela/ing B/aggerated res!onse of SMC to sym!atetic stimulation Sym!atetic !atway is overstimulated Color cange H wite" .lue" red H %8O !reci!itated .y cold" 2O .y emotions #ifferentiate s!astic #2SBASB , !rimary VS o.structive S=N#ROMB ,secondary S!asticC 'VR and waveforms normal at room tem!" worse wit cold O.structiveC a( "oom (em5e"a(u"e 2 ;EE abno"ma+ .GR #iagnosis of #2SBASBC termal test done only wen o.structive com!onent is e/cluded& Barly vasosas!m wit tem!erature dro! 0two cuffsC !ro/imal digit cold" distal digit warm1 Recover ta:es Q 20 min ?ave reactive y!eremia on rewarming See 'ea:ed !ulse 0suggestive of vasos!asm1 20O of Raynaud9s ave scleroderma" 80O of scleroderma ave Raynaude9s MC5# H *O Aterosclerosis H 8O 3uerger H FO Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age *% Canadian Vascular Surgery Minimum 5reatmentC Avoid cold" .eta.loc:ers" smo:ing CC3" al!a .loc:ers" yoim.in el!ful 2n rare cases H consider sym!atectomy 'rognosticate H o Bvaluate !resence of sym!toms of C5# o 'erform C5# anti.ody screen if C5# screen !ositive" !atient may ave !rogession to o.structive !attern i&e& in tis case" dealing wit early Raynaud9s syndrome NO5 4ust Raynaud9s disease o 2f tere are no C5# sym!toms at !resentation Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age G0 Canadian Vascular Surgery Minimum ris: of C5# is GO at E&E& years o 2f sym!toms of C5# are !resentC ris: of C5# is ig 0 u! to *0O 1 62.Connecti*e tissue disorders: Systemic sclerosis 0a:a scleroderma1 o Strictly s!ea:ing H small vessel VASCUAO'A5?=" NO5 VASCUA252S o J)T an in'+amma(o"$ &as%u+i(is Ai:ely due to SMC !roliferation o Auminal narrowing o Most commonly C5# associated wit Rayaud9s o Un:nown etiology o 6i.rosis of s:in and internal organs \ Su.ty!es of sclerodermaC o #iffuseC 10 $ea" su"&i&a+ 40/A0K 'ulm y!ertension Renal failure o Aimited scleroderma CRBS5 10 $ea" su"&i&a+ L0K Calcinosis" raynaudes" eso!ageal dismotility" sclredodactyliy" telangectasia More .enign Aess eartLlungL:idney !ro.lems #iagnosisC Clinical A3C o 'ositive ANA s!ec:led !attern seen in %*O of !t NONS'BC262C see also in SAB , omogenious o Scl,+0 more s!ecific o E;R J)RMAL SAB o =oung females" .ut all age grou!s are susce!ti.le o Artlagia" s:in ras" !ericarditis" !leuritis" Klomerulone!ritis o 'ositive ANA H omogenious !attern o Raynaud !enomenon is seen in +0O Reumatoid artritis and S4ogrenC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age G) Canadian Vascular Surgery Minimum o Small vessel vasculitis wit o.literative fi.rosis Mi/ed C5#C o Overla! of two C5# Usually SAB and Scleroderma 'olyarterirtis Mi/ed .ag 63. Diffirential diagnosis of positi*e A(A: SAB H omogenious ANA Sclreroderma H s!ec:led ANA CRBS5 H anticentromere A3 64.-asculitis: Tab+e 38/M8 F+assi'i%a(ion o' Gas%u+i(is1 Gesse+ size AJFA JEIAT9GE AJFA .);9T9GE Aarge 5a:ayasu]s arteritis , Kiant cell arteritis , Medium Iawasa:i]s disease Curg,Strauss angiitis 0',ANCA1 'olyarteritis nodosa , 3e^et]s disease , #rug a.use vasculitis , Small ?enoc,Sc_nlein !ur!ura -egener]s granulomatosis 0C,ANIA1 Bssential cryoglo.ulinemia Microsco!ic !olyangiitis 0',ANIA1 Arteritis of connective tissue 0Scl" SAB" RA" MC5#1 65.&ypes of &akayasu Arteritis: modified Ueno classification aortic arc onlyC F0O descending toracic and a.do aorta H middle aortic syndrome C ))O involves .ot )& and 2& C G*O !ulmonary artery involvement PL, ),EC )*O all to a a!!y total of )E)O Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age G2 Canadian Vascular Surgery Minimum
RuterfordC most common large vessel arteritis disease of te young R E0 year olds .ot stenotic and aneurismal disease in NA" most common !resentation is u!!er lim. iscemia" closely followed .y CVA& ?5N in EE,88O o renal a& stenosis" may .e missed unless !ressure in .ot arms is measured 2solated AAA Aortic regurgitation 0ascending a& dilation1 H 20O 'ulmonary ?5N 0une/!lained dys!nea1 10K o' a%(i&e disease ha&e no"ma+ FR. and E;R Most often disease is diagnosed at reconstruction o i&e& not in an active stage Un:nown etiology" 'an,arteritis" 'atcy involvement Kranulomatous lesions" .ut no caseation and cavitation #isease is transmural o i&e& tere is NO role endarterectomy or !atc angio!lasty H !refer .y!assM Res!onds to systemic steroids and cytoto/ic drugs o if in active stage StagesC 'rodromal !art 2nflammatory 3urned out Clinical !resentationsC Stro:e C?6 ?5N Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age GE Canadian Vascular Surgery Minimum CR6 Aneurysm 'ulm ?5N Aortic regurgitation o Mortality due to uncontrolled y!ertensionC stro:e" C?6 o Can9t follow stages using la.s" need to ave serial imaging& o Main !atology is stenosisLo.struction" occasionally aneurysmC o Surgery is contem!lated in .urnt out stage only o Aong stenosis H o S!aring ascending aorta 0in %*O of cases1 o carotid .y!ass to te level of te carotid .ul. o Renal artery may consider '5A ) st for renal a& stenosis !oor long term results for oter locations o 2nfrarenal aorta H u! to 0.ut not at1 te level of .ifurcation May consider toracic aorta ,Q single iliac .y!ass H will re!erfuse te oter e/tremity via !reserved .ifurcationM o 2nnominate arteryLsu.clavianC 3y!ass to su.clavianLa/illary artery H Not for iscemic sym!toms 'rimaly !ur!oseC to .e a.le to diagnose ?5N 0.y arm 3' measurement1 Com!lications of ?5N is te most im!ortant cause of mortality in 5a:M 2m!ortantC ma:e sure disease is in .urned out stage .efore .y!assing& 66.7iant cell arteritis: Blderly affected 'redominantly middle si;ed vessels and aortic involvement 6re>uent involvement of BCA .rances" including o!talmic artery o 'ainful tem!oral a& o Retinal iscemia leads to .lindness o $aw claudication in *0O Can ave aortic arc involvement only 'olymyalgia reumatica common Criteria of Am Col ReumatologyC o Age Q *0 yoa o Aocali;ed eadace Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age GF Canadian Vascular Surgery Minimum o 5em! artery tenderness on e/am o BSR Q *0 o 5A .io!sy !ositive for KCA U! to 20O of !ts ave normal ./ F0O negative wit aortic arc syndrome only 67.,e"cet disease diagnosis: o Systemic vasculitis" un:nown origin o ?allmar:C OralLgenital ulcers and recurrent uveitis o NO la. mar:ers #iagnostic criteriaC o Ma4or H oral ulcers o MinorC need 2 Kenital lesionsC recurrent ulcer Bye lesionsC AntL!ost uveitisLretinal vasculo!aty H seen in 80O o May lead to .lindness S:in lesionsC erytema nodosum" !seudofolliculitis" acne" 'atergyC o clear !ustule F8 !ost s:in !uncture OterC venous trom.osis 0UB" AB" SVC" 2VC1 o MOS5 COMMON VBSSBA 'A5?OAOK= *0O of !ts o #ue toC o 'rotrom.ic state o Bndotelial in4ury o #efective fi.rinolysis Arterial !atologyC o SBCON# MOS5 COMMON VBSSBA 'A5? U! to EFO of !ts o aneurysms , more common tan occlusive AAA Q!ulm Qfem Q!o!Q.racial Qiliac Leading %ause o' dea(h in <D 2 RH.THRE 2ntracranial aneurysms descri.ed o occlusive arterial disease AB and UB .etter !rognosis Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age G* Canadian Vascular Surgery Minimum increased ris: of .y!ass trom.osis !ericardis E,GO Artritis K2 ulcers CNS 0sei;uresLmeningitisL!alsy1" Klomerulone!ritis , +&*O SummaryC o sore mout AN# sore eyeL!enisLs:inLoter o !atergy o die from AAA ru!ture o no la. test" clinical diagnosis o more venous rater tan arterial !ro.lems 5reatmentC o 2mmunosu!!ressive for o!talmicLneurologicLvascular com!lications o No serologic mar:ers to follow o Aarge dose steroids for vascular" may need second agent o Cyclos!orine o 6or oralLgenital ulcers H 5?AA2#OM2#B o if tis drug is given for females" consider doing ysterectomy or 5A first 68.O&HR #id 3 s!all *essel *asculitis: o 'AN H !olyarteritis nodosa Systemic necroti;ing vasculitis AneurysmsLru!turesLtrom.osis in any organ Common !resentationC a.do !ain in young adults o Mesenteric aneurismal involvement BSR u!" .ut ANCA is negative Angio H multi!le visceral aneurysms ?e! 3 antigen !ositive in E0O" associated wit ?2V o Iawasa:iC Affects infantsLcildren R *yoa 20,E0O , coronary aneurysm OterC !ericardial effusion" MR" C?6 Multi!le oter 0aorta" viscera1 aneurysms wit age o Curg,Strauss H tree stages i1 Allergic !ase H sinusitis" rinitis" Astma ii1 Bosino!ilia wit eosino!ilic infiltrates !neumonia" gastroenteritis" neuro!aty Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age GG Canadian Vascular Surgery Minimum iii1 Vasculitis Mc site Hcoronary" .ut any vessel can .e involved o .,ANCA !ositive o More .ro/imal vessels involved 69. S!all *essel arteritis: o -egener9s Necroti;ing granulomatous vasc Classic lesionsC Iidney and U!!er res! tract 'resentationC digital iscemia and nail fold infarct F/AJFA 5osi(i&e in N0K in a%(i&e disease o Microsco!ic !olyangiitis $ust vasculitis of small vessesl" ',ANCA !ositive 70. S!all *essel pat"ology leading to digital is"c"e!ia: DD ANCA !ositiveC o Microsco!ic !olyangiitis o -egener9s ANCA negativeC o C5# o Cryoglo.ulinemia 5raumaC o Vi.ration o 6rost em.olic 71.Arteritis associated wit" aneurys! for!ation: o 5a:ayasu o 'AN o Iawasa:i o 3ecet o #rug induced Oter -<- conditions tat can ave AAAC Blers,#anlos" Marfan" 5urner" 'CI# WEIRD & WONDERFUL 72.,uerger5s disease diagnostic criteria: o 'redominantly male" .ut may see in female Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age G+ Canadian Vascular Surgery Minimum 2n Nort America" u! to )*,E0O of !ts are -OMBN o Onset R F* yoa o Smo:ing / o 2nfra!o!litealLinfra.racial arterial involvement leading to iscemia documented clinically 0R'" ulcer1 and o.4ectively o No oter R6 for aterosclerosis 0#M" tn" li!ids1 o Bco and angio e/clusion ofC !ro/imal em.olism 0cardiac" 5OS" aneu" arc" atero1 trauma local lesions 0adv cyst d" !o! entra!ment1 o Aa. test e/clusion of autoimmune" C5#" #M" myelo!roliferative #O o Oter featuresC Migratory !le.itis" Raynaud9s" inste! claudication BtiologyC no one :nows" smo:ing" genetics" y!ercoag and endotelial dysfunction" immunologic mecanism ?istologicallyC trom.us is inflammatory inner elastic lamina is spared no acute !ase reactants 0unless acute infarction of lim.1 mar:ers of immune,activation are a.sent discontinuous lesions SummaryC distal arterial disease -25? smo:ing -25?OU5 #M" li!id" ?5N" em.olus" C5#" myelo 5reatmentC Sto! smo:ing" no nicotin !atcesLgum" !ain management" ASA" CaC3" ilo!rost" de.ride" .y!ass or am!utate if necessary 'ain control H s!inal cord stimulator Am!utation rateC in smo:ers H FEO" e/,smo:ers H GO 73.Angiograp"ic features of ,uerger5s disease: o Normal !ro/imal a& i&e& no ateroscelrosis o 2nvolvement of vessels distal to .racial and !o! artery Segmental involvement 0normal intermingles wit a.normal1 Severity increases distally Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age G8 Canadian Vascular Surgery Minimum o Collaterali;ation in te vasa,vasorum H cor:,screw collaterals o No source of em.olism 74.0nco!!on causes of aneurys!s Arteritis 0see a.ove1 MarfanC Must ave clinical findings" not genetically documented classic 63N) mutations alone 2*O of te !atients ave new mutation #efective elastic tissue #isease continuum 5all tin" long armLlegs" ArmLeigt Q )&0* 'ectus carinatumLe/cavatum Aortic dilation Ascending involved in 80O 33 !ro!yla/is essential Re!lace ascending aortaLsinus wen Q* cm 2n !regnancy H use 33" dilation to Q Fcm is ig ris: for ru!ture Blers,#anlosC Collagen syntesis !ro.lem S:in y!erelasticity" fragility" 4oint y!ermo.ility )) ty!es H diverse clinical !resentation 5y!e G as vascular relevance Only FO of all ty!es ReducedLa.normal ty!e F collagen o 5in s:in" easy .ruises" o 7Alien from te flying saucer8 face 0tin li!s" !rominent eyes" narrow nose" no sc fat1 Most relevant !resentation is 'erforationC o Vessels o Uterus H )),2*O of !regnancies in tese !ts o Colon 0sigmoid1 MC cause of deat H arterial ru!ture Multi!le aneurysms" only )GO aware of diagnosis !rior to ru!ture o Unusual com!artement syndroms 0.uttoc: wit gluteal a& ru!ture1 2n emergency" ligation !refera.le to .y!ass Bndo may ave role Avoid s!orts 5urner" !olycystic :idney associtated wit 5AA Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age G% Canadian Vascular Surgery Minimum 75.&ypes of collagen: o ) HMC" %0O" tendons" ligs" .ones o 2 H yaline cartilage o E H vascular structures and colon o F < * H .asement mem.ranes and C5 matri/ 76. 1eatures of pseudoxant"o!a elasticu!? May !resent as young male wit retinal emorrage" coronary artery disease" and .ilateral leg claudications& 'seudo/antoma elasticumC o C5# tat causes elastin degeneration ,Q calcification o 'redis!oses to Barly AKRBSS2VB diffuse aterosclerosis o +0O of !atients are R E* yoa o S:in" eye" cardiovascular system o Jantomas along nec:Lgroin fle/ion lines 0cic:en s:in1 o S!ontaneous retinal emorrages ,Q .lindness CA# o #on9t use A2MALR2MA" only KSVM Stro:e Soft tissue calcification 0el.ow" i!1 o #d trauma" scleroderma" y!er '5? Aggressive aterosclerosis R6 modification& 77.Pat"ology of radiation *asculitis: o Causes accelerated aterosclerosis o 2n4ury to vasa,vasorum o 2scemic necrosis of vessel wall o 6i.rosis of internal elastic lamina o 5ic:ening of adventitia o Aong smoot ta!ering stenosis 78.Clinical syndro!es associated wit" cystic !edial necrosis: o Marfan o Blers,#anlos o Some ty!es of Neurofi.romatosis o All muco!olysaccaridoses Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age +0 Canadian Vascular Surgery Minimum ?yaline degeneration of media" re!lacement wit mucoid .aso!ilc su.stance& 'resents asC )& AorticLcarotid dissection 2& #isseminated arterial ru!ture E& S!ontaneous ru!ture 79.-isceral Splanc"nic Artery aneursy!s: S!lenic 0G0O1" e!atic 020O1" SMA 0GO1" Celiac 0F O1 KastricLgasroe!i!loic 0FO1" intestinalL!ancreatic 02O1& i&e& After celiac" go cloc:wiseC gastric" gastroe!i!loic" intestinal" !ancreatic 80.Classification of splenic a@ aneurys!s: Usually saccular" at .ifurcations" multi!le in 20O& o 5rue Associated wit arterial fi.rodys!lasia 06M#1 Associate wit !ortal ?5NLs!lenomegaly 'regnancy induced 0multi!arity1 rLo 'AN" Iawasa:i" Blers,#anlos o 6alse 'ancreatitis induced 5rauma o 'enetrating o 3lunt infected 81.Indications and treat!ent for splenic artery aneurys! repair: o Q2 cm in good ris: !ts" some say Q E cm o 'regnant or 'otentially !regnant !t o Sym!tomatic Ru!ture , R 2O o 2f !regnant H %*O of aneurysm diagnosed during !regnancy are ru!tured o #ou.le ru!ture H first in lesser sac:" ten !eriotoneal cavity Re!airC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age +) Canadian Vascular Surgery Minimum ligate or s!lenectomy 6or !ro/imalC sim!le ligationLe/clusion no reconstruction MidC usually false aneurysms associated wit !ancreatitis o ligation" o ten o!en aneurysm" o ligate .rancesLartery form witin #istal H s!lenectomy 82.Hepatic a@ aneurys!: o 2 times more common in males o 2*O medial degeneration H MC cause according to Ruterford Com!anio n 2n E* O aterosclerosis is seen H .ut tis is co,incidental o 22O !seudoaneurysm trauma o )*O mycotic due to 2V drug a.use o Oter causesC 'AN 5rauma" am!etamines o 80O e/trae!atic" 20O e!atic o 20O ru!ture rate o May ligate if in C?A" o e!atic artery .rances involvement may re>uire reconstruction& o ?e!atic locali;ationC Bm.olectomy vs lo.ectomy 83.S#A/ celiac/ gastroepiploic aneurys!: o SMA G0O mycotic Current !a!ers says less Non,emolytic stre! More common in younger 20O aterosclerosis #rugs H cocain and ergot Ru!ture can .e seen in u! to F0O #o not stent teseM o Celiac aneurysm H mostly degenerative 0i&e& secondary to aterosclerosis1 ru!ture )EO o Kastroe!i!loic Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age +2 Canadian Vascular Surgery Minimum 2f see multi!le onces" !articularly in K#A distri.ution H loo: for ig flow situation %0O !resent wit ru!ture +0O into K2 E0O intra!eritoneal AigateLem.olise all 84. Renal a@ aneurys!: #egenerative o 6M# o Vasculitits o 'AN o 3ecet %0O e/trarenal EO ru!ture Re!air inC o 2m!regnata.le females o Sym!tomatic ?tn ?ematuria 'ain ?ydrone!rosis o QE,F cm in asym!tomatic 85.Co!plex regional pain syndro!e : A:a causalgiaM o 5is syndrome is %om5+e7 involves autonomic" vascular" motor" cutaneous" inflammatory canges o it is "egiona+ s/s and findings are .eyond te original region of in4ury o it is very 5ainful severity usually out of !ro!ortion to te initiating event o 5y!e ) H due to inciting no/ious event 5rauma 0MC1 Non,traumatic o 'ost !rolonged .ed rest o 'ost M2LCVALneo!lasms Soulder,and syndrome 2dio!atic o 5y!e 2 H due to nerve in4ury Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age +E Canadian Vascular Surgery Minimum flare,Qdystro!y,Qatro!y o Stage 2 acuteC ?ot<sweaty" swollen" .urning y!er,!ain 5/C !ysical tera!y main stay& 2f can9t do tis .ecause of !ain" try S=MA5?B52C 3AOCI H may .e long lasting steroids" local nerve .loc:" 5BNS 0transcutaneous electric nerve stimulator1 o Stage 22 dystro!icC cold" mottled" osteo!oroticL.rittle nails" continuous !ain 5/C !ysio .ut may try sym!atectomy UNABSS tere is dramatic res!onse to sym!atetic 3AOCI first" do not go for sym!atectomy 5BNs" steroids o Stage 222 atro!icC atro!ic" contracted" !ain elsewere 5/C sym!atectomy less successful" !ysio" 5BNs" antide!ressant Most el!ful confirming diagnostic feature of CR'S is RBS'ONSB to sym!atetic .loc:& Oter tests H a.normal sweating" termogra!y& 86.&ypes of 1#D: CauseC Bstrogen effect Mural iscemia 0lac: of .rances1 Re!etitive trauma 0.ending and stretcing1 5in: of $a..a te ?utt H toug fi.rous core" toug fi.rousLy!er!lentiful middle" malignantLdys!lastic e/teriorM o 2nside H intimal 623RO !lasia H *O MUf o Middle H medial 623RO !lasia H 8*O most common medial ?='BR !lasia H )O rare o !erimedial #=S'AAS2A H )0O Most common is medial fi.ro!lasia Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age +F Canadian Vascular Surgery Minimum String of .eads aneurismal dilatation Midd+e (o dis(a+ "ena+ a8 a''e%(ed .Ll in **O R sided more common tan A ?istology H o fi.rous connective tissue re!laces Smoot Muscle Cells )0O ave .erry aneurysms in ead o 80O solitary o 20O multi!le 87. #ost co!!on arteries affected wit" 1#DA o Renal artery o Carotid arteries 0&FO of all carotid angios sow tis" G*O .ilateral o B/ternal 2liac arteries 5reatment of RBNAA 6M#C '5AM 5reatment of CARO52# 6M#C Standard H o!en gradual intraluminal dilation& 2 mm to G mm to te .ase of te s:ull" .ac: flus de.ree from 2CA& Oter o!tionC '5A" .ut in a review of )+0 cases *O ad neuro deficit& Clinical Scenarios in Vasc Surgery do not recommend tis as a 88. Portal "ypertension and .leed: 5reat definitively after first .leeding e!isode o +0O will re.leed wit +*O mortality rate 3anding and o.servation is contraindicated if !t leaves far away o #oes not wor: well for gastric vari/ 3eta .loc:ers reduce re.leed .y *0O 52'S H %0O success" .ut 2*O !ortosystemic ence!alo!aty 89.Indication to treat *asc !alfo!ations: o a.solute local effectsC distal stealLiscemia non,ealing ulcer .leeding Aeg lengt discre!ancy Aneurismal degeneration systemic effectsC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age +* Canadian Vascular Surgery Minimum C?6 #2C o RelativeC Cosmesis #isa.ling 'ain Aimiting claudication Com!ression of structures 90. Ha!.urg classification of *ascular !alfor!ations: 5umors o A.normal endotelial turnover o MC infantile emangioma Starts at .irt .ut usually seen at 2L*2 Krows wit cild" regresses wit age %0O gone .y % yoa Malformations o Normal endotelial turnover 91.4lippel)&renaunay: o Slow flow AVM o soft tissueLs:eletal y!ertro!y o Ca!illary malformation Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age +G Canadian Vascular Surgery Minimum o Aym!atic y!er!lasia o Anomalous lateral leg vein of Servelle o OterC ematuria" ematoce;ia" consti!ation" .ladder outlet o.struction 'ar:es we..er H same !lus Clinically 6AS5 flow AVM& I5 as tem too .ut it is micro and not clinically significantM 6acial V),V2 ca!illary malformation H sus!ect intracranialLle!tomeningealLori.tital vasc malformation& VE carries no suc !ros!ect& 92. Sclerot"erapy: 6or varicosities H etanolamine" !olidocanol" NO5 etanol VM H S5#" etanol& 93. -ascular tu!ors: Vascular leyomyosarcomaC o Most commonly found in 2VC" not arteries& #ismal survival H discovered wit mets& MC tumor to grow into 2VC H RCC MC tumore to o.literate 2VC in R' , sarcoma 94.Congenital defects and sy!pto!s: #ou.le aortic arc H o vasc ring around tracLeso!agus" ,Q dys!agiaLdys!nea #uctus arteriosus H o Mos( %ommon %ongeni(a+ abno"ma+i($ o sunt from aorta into !ulm artery ,Q !ulm ?5N R a..erant su.clavian a& H o 5a:es off distal to Aeft su.clavian artery" .eind 5racLBso or .etween tracea and eso!agus" causing to dys!agia lusoria < dys!nea o May ave aneurismal dilatation at origin 0:nown as Iommeroll diverticulum1 'ersistent sciatic artery , o !rone to aneurismal dilation 3ovine arc H 2nnominate and A CCA are 4oinedC o 5rue common trun: seen in 8O" common origin only is )GO A verte.ral off aortic arcC 8O 95. Persistent sciatic artery: o 'ersistence of fetal circulation o Off internal iliac" down to !o!liteal along sciatic n" Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age ++ Canadian Vascular Surgery Minimum diminutive S6A !resent" no femoral !ulse o 'rone to degeneration o 'resents wit .uttoc: mass" emo.li;aiton" sciatic nerve !ressure" em.oli;ation o +0O unilateral o 'o! !ulse .ut no femoral !ulse o Aneurysm in F0O at greater trocanter o Re!air aneurysm vs ligation !lus fem,!o! .y!ass 96. A..erant Rt@ Su.cla*ian artery: o 0&*,)O of !eo!le o Caused .y involution of R F t aortic arc& o 2nstead" R su.clavian artery forms from + t intersegmental artery dis(a+ to A su.clavian artery o 'asses usually !osterior to eso!agus" .ut can !ass .tw eso!agus 80O" trac )*O" anterior to trac *O o Can result in dys!agia lusoria o NoteC dys!agia lusoria can .e caused .y !ersistent a..erant A SCA originating from R sided arc !ressing on eso!agus& RARB o Iommerell9s diverticulum H remnant of te F t aortic arc at te aorta o According to Ruterford te/t" re!air only for sym!toms or QF cm in asym!tomatic !t o Re!airC endo e/clusion !lus e/tratoracic reconstruction 0y.rid1 .ranced endo graft o 2f Iommerell is seen H wic is most of te cases need eiter .ranced endo" aortic arc re!air o 'ts will also ave .ovine arc" A verte.ral ta:ing off aortic arc" R sided toracic duct and anomalous R recurrent laryngeal nerve H direct course off vagus& 97. %"at is re2uired to "a*e a nor!al erection? o NervesC Nervi erigentes H sym!atetic 5)2,AF and !arasym!atetic S2,SF o 'arasym!atetic H Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age +8 Canadian Vascular Surgery Minimum cause vasodilation" leads to tumescence o Sym!atetic H Regulates e4aculation nerves form !le/us at te root of 2MA and aortic .ifurcation& Nerves course anterior to A common iliac artery o Careful wit dissection o ArteriesC 2nternal !udendal a& H need tis as a re>uirement for successful erection Mecanism of erectionC 2ncreased arterial inflow into cor!oreal .odies Normally .lood in cavernous .ody is desaturated& -it .lood flow" o/ygenation of cavernosal nerves and endotelium !roduces more NO o i&e& ?y!o/ia decreases NO NO stimulates cKM' !roduction o !romotes SMC rela/ation 2nfilling of te cavernous .ody and SMC rela/ationC o distends !enis and occludes venous outflow& o 'ressure goes from )* mm to %0 mm Bventually" at ma/imum u!ward !osture" cavernous artery 0center1 flow ceases& o Ma/imum !ressure of )20 is reaced& o -it reduced flow" desaturation ta:es !lace ,Q te ting goes flaccidM 98. rectile disorder: o 'ersistentLre!eated ina.ility to acieve erection to !erform an intercourse o At least E monts o No e4aculatory disorder Fauses o' d$s'un%(ion- Most common underlying mecanism H failure of cavernosal smoot muscle rela/ation& Vascular 0macro AN# micro circulation1 Bndocrine H E,FO Meta.olic Neurogenic 'sycologic #rug induced H o Antiy!ertensive Note ACB2 are s!aring Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age +% Canadian Vascular Surgery Minimum 5o test for vascular insufficiency" try 'KB) in4ection H if ade>uate errection is acieved" ten vascular su!!ly is o:& Vascular causesC 'oor arterial inflow A2O# Steal to e/ternal iliac artery Occlusive disease of !enile arteries Ateroem.olic occlusions 3lood !ressure effect on arteries 03eta .loc:ers1 Venous lea:s at te cavernosum .odies 5rauma to tunica al.ugenea Congenital lea:age cavernosum is messed u! o 6i.rosis 0!ost !ria!ism1 o 'eyronie9s H deformity invading into SMC o Refractory smoot muscle H does not res!ond to stimulation ?ormonal 0!rolactin" low testosterone".lood !ressure med1 Meta.olic 0#M" uremia1 -or: u!C 'rolactin" testosterone" glucose" 'SA 'KB) in4ection T"$ o"a+ d"ugs 'i"s(, ten intracavernous in4ection" ten vacuume constrictors& o Sildenafil is NO5 recommended for women 26 tese fail" ten invasive testing H angioLvenogram& 2f tese fail wit additional trial of #rugsL2C2LVC H ten try !rostesis& EMBOLISM, THROMBOSIS & LIMB ISCHEMIA IN GENERAL 99. Causes of arterial occlusion in general: em.olism trom.osis !re,e/isting occlusive disease ru!tured !la>ue !oor inflowC low flow state sluggis .lood flow leading to trom.osis .y!assLconduit occlusion Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 80 Canadian Vascular Surgery Minimum disease mecanical !ro.lem outflow occlusion .lood flow .ac:ed u! leading to trom.osis y!ercoagula.le state trom.osis in normal vessels congenital" malignancy" !ost,o!" trauma trauma < dissection disru!tion of normal vessel 100. #ost co!!on sources of e!.olis!: eart o ASC eart diseaseC M2" Arrytmias o Atrial my/oma o Valvular eart diseaseC R6" #egenerative" Congenital" 3acterial" 'rostetic artery to arteryC aneurysm" aterosclerotic !la>ue 2dio!atic 'arado/ical o 'atent foramen ovale H u! to 2*O of !o!ulation ave it 101. #ost co!!on sites of e!.olisation: o femoral H MC H E*,*0O o !o!liteal H 2 nd MC H 20,E0O o cere.ral H 20O o u!!er e/teremity H )*O o visceral H )0O #uring em.olectomy" longitudinal arteriotomy is recommended H if em.olectomy fails" may do .y!ass& Use A2R for `) and 2 6ogarty H air is more res!onsive to cange in diameter tan saline H less cance of endotelial in4ury& Aivido Reticularis H most common cutaneous sign of microateroem.oism 0tras foot and tras can1& Sym!tom wise" can see fatigue and weigt loss if ateroem.olism is dissiminated& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 8) Canadian Vascular Surgery Minimum 102. At"eroe!.olic Renal falure: i@e@ parenc"i!al causes? ## o A5N due to contrast ne!ro!aty o A5N due to iscemia o Bmtolism Arterio,arterial Cardiac em.olism Clot Atrial my/oma S3B" A3B o -eird and wonderfulC Necroti;ing vasculitis 5rom.otic trom.ocyto!enic !ur!ura Anti!os!oli!id anti.ody Multi!le myeloma Aa. H unel!ful in general o Bosino!ilia in ateroem.olism o BSR" CR' u! o UA H see urine sediment in A5N 0dirty .rown cast1 2m!ortant to distinguis contrast vs iscemiaC o Consider time,frameC Contrast ne!ro!atyLA5N H renal failure witin +2 renal failure usually recovers no"ma+ b+ood 5"essu"e8 i8e no HTJ Ateroem.olism H rise in creatinine may .e delayed .y a wee: "e'"a%(o"$ h$5e"(ension renal failure mostly non,refersi.le !oor outcomeC ) year mortality GF,8)O" due to cardiac" CVA" K2 iscemia 5reatment and !reventionC )& Sta.ili;e !la>ueC Statins Anti!latelets ACB2 'latelet infusionsD 2lo!rostD 0see Ruterford" does wor: in some studies1 2& Surgical control of source a& Only if medical tera!y failed Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 82 Canadian Vascular Surgery Minimum .& O!en surgery vs endo ArcLtoracic aorta !la>ue H if Q*mm tic:C o EEO annual ris: of vascular events vs +O in control& Overall" non,calcified < at least F mm !la>ue are a ris: factor for ateroem.olism o 2t is suggested to start warfarin on tese !ts 0ACC'" 200)1 3etter ten ASA alone Com.ined wit statin Surgery o O!tion for minority only o only on igly selected !ts" low OR ris:" ave multi!le documented em.olic events des!ite medical tera!y see aorta !art of oral in training e/amsM& 103. Causes of arterial t"ro!.osis: o Aterosclerosis H e/!osed ru!tured !la>ue o Aow flowC C?6 cardiogenic soc: y!otension o vascular graft trom.ogenic disease !rogression in graft 0Aterosclerosis1 initimal y!er!lasia mecanicalC :in:" valve o traumaC intimal fla! vs s!asm vs com!ression !enetrating .lunt drug a.use o y!ercoagula.le state 0see .elow1 o outflow o.structionC arterial H disease !rogression" dissection venous H com!artment" !legmasia 104. tiology of post op acute $eg isc"e!ia post AAA repair: Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 8E Canadian Vascular Surgery Minimum Most common RBCOKN2YA3AB causeC Raised intimal fla! 2*O Iin:ing 8O 'ost o! y!otension 8O Causes e/!andedC o 5rom.osisC lim. of #acron graft diseased iliac" C6A" S6A" !rofunda !o! a& aneurysm o em.oliC trom.us from te eart from !ro/imal vessel wit inade>uate e!arini;ation dislodged !l>ue 0ateroem.oli1 5o !reventC )& ?e!arini;e !t !rior to clam!ing 2& 3ac: .leed iliacs !rior to !ro/imal clam! removal E& 6lus graft !rior to distal clam! removal F& Ai.eral use of 6ogarty *& #o not leave OR witout cec:ing feet first G& #o not clam! C2A a& Clam! 2AA and B2A instead" less cance will tras clot in C2A downstream ManagementC )& 're! .ot groins 2& B/!lore inde/ groinC a& Cec: inflow .& Cec: anastomosis c& Cec: S6AL!rofunda E& Consider trom.ectomy vs fem,fem vs a/fem F& Consider !rofundo!lasty *& Monitor ?g and consider fasciotomies if Q G iscemia 105. Infrainguinal graft t"ro!.osis: o Barly failure rate *,)0O witin E0 days o 3ad !rognosis even in successfully trom.ectemi;ed graftsC At ) year H *0O am!" 2*O R'" )*O died o A!!roacC Confirm trom.osis Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 8F Canadian Vascular Surgery Minimum Minimi;e clot !ro!agation 0AC1 Assess neurologic and motor status Review indication for .y!ass 02C vs R'Lulcer1 #ecide if need to intervene at all #ecide if graft can .e salvaged See wat conduits are availa.le CauseC Kraft trom.ogenicity y!ercoag state !oor run off !oor inflow undetected asc disease !oor cardiac out!ut o deydration o cardiac decom!ensation in A0K o' %ases 'ai+u"e is due (o (he %ondui( 5"ob+ems 80K o' (hese is %o""e%(ab+e Te%hni%a+ e""o"s "es5onsib+e 'o" 4/3MK g"a'( 'ai+u"es A( e75+o"a(ion, M0K o' g"a'(s ha&e no a55a"en( 5"ob+ems8 2f decided to salvage" decide surgery vs trom.olysis& Results of .ot are !oor& o lysis won9t el! in !ts wit #M < recent graft& 'refer surgery for most Outcome is .etter if tecnical !ro.lem 0cus!" twist or stensis1 is identified& See notes on 5rom.olysis 106.Isc"e!ia 3 reperfusion effects on organs: 2scemia de!letes intracellular energy sourceC o switc to anaero.ic meta.olism o generation of to/ic radicals& o Adesion molecules generated H inflammatory cells come in o 2n te endC Organel and cell mem.ranes are disru!ted as ionic !um!s sto! 2nflu/ of CaPP causes cell deat and fluid e/travasation 5ransudation of fluid cauase edema and ca!illary occlusion o Re!erfusion effects H wases out cell deat de.rie into circulation H Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 8* Canadian Vascular Surgery Minimum ig I" urea" acid" myoglo.in o arrytmias and renal failure .rings in o/ygen to damaged tissues o/ygen free radicals form& radicals overwelm damaged antio/idant system H cause furter damage to ealty" surviving mem.ranes H furter cell damage& o S2RS and organ dysfunction o No reflow !enomenon wit re!erfusionC Mini,com!artment syndrome No o.vious o.struction No flow troug microca!illary .ed Unclear etiology& #escri.ed in coronary literature 07.ro:en eart syndrome81 Several causes seenC s!asm of te microcirculation" local !latelet activation" microvessel em.oli;ation tissue edema COAGULATION & ANTICOAGULATION 107. Su!!ari>e coagulation cascade: B/trinsic H o tissue factor activates V22 o V22a activates small amount of factor J AJD 'a%(o" 9O8 5is re!resents an im!ortant feature H CROSS tal: to 2ntrinsic !atway V22a is >uic:ly inactivated .y 5issue 6actor 'atway 2ni.itor o Ja 0initially activated .y V22a1 activates small amount of V222 and V o activated factors 2J 0from V22a1" V222 0from Ja1" and !lus Ca 2P form tenase com!le/ on te surface of !!t *0 times more active tan V22a& Massive amounts of Ja are formed o Ja" Va" Ca 2P and !!t activate trom.in tat converts fi.rinogen to fi.rin& 2ntrinsicC J22,QJ2,Q2JM Common !atway H J activates 22" 22 creates fi.rin Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 8G Canadian Vascular Surgery Minimum 3ut te most im!ortant source of activated factor J is from tenase action& 6i.in is sta.ili;ed .y factor J222 .+asmin inhibi(o"s- 5"o%oagu+an(s: 'lasminogen Activator 2ni.itor H ) 0'A2,)1 o inactivates t'AM o e/cess causes arterial AN# venous y!ercoagula.le state Al!a 2 anti!lasmin o 2ni.ited .y de/tran F0 An(i%oagu+a(ion a"m- 'lasmin H .rea:s down fi.rin o 2ni.ited .y 'A2,) and al!a2,anti!lasmin Antitrom.in 222 H o Always active o Action is am!lified .y te !resence of ?e!arin o Most sensitive en;ymes to e!,A5222 is factor 22 Also wor:s vs 2J" J" J2" 'rorein C , Q .inds trom.in and ten trom.omodulin& o 5is activates 'nC and" togeter wit !n S" .loc:s factor V and V222& 6actor V222 is needed for activation of factor J 6actor V is needed for activation of factor 22 maPo" an(i%oagu+an( "esis(an%e o' 'a%(o" G (o A.F is MF %ause o' H$5e"%oagu+ab+e s(a(e 5rom.omodulin H Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 8+ Canadian Vascular Surgery Minimum o .inds trom.in inactivating it& o it accelerates activation of !rotein C tousand fold& t'A H activator of !lasminogen" secreated .y endotelium 5issue !atway !atway ini.itor 05''21 , anticoagulant o 'rotein tat inactivates V22a and Ja o Most of it is .ound .y endotelium and can .e released .y e!arin o ?as anti,inflammatory !ro!erties 'rostocyclin H o generates cAM' H reduces !latelet aggregation 108. How does Dextran B: work? o 'olysaccaride o 2ncreases electronegativity of R3C" !lt" w.c" reduces aggregation o 2ni.its al!a,2 anti!lasmin o Reduces factor V222,V- activity o #ecreases viscocity Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 88 Canadian Vascular Surgery Minimum o +0O eliminated witin 2F 0urine1 o Com!licationsC May aggravate renal failure 0diuretic1 Ana!yla/is 'ulm edema Cere.ral edema 109.%arfarin: !ec"anis! of action and co!plications: o 2nterfers wit utili;ation of vit I .y te liver during syntesis of J" 2J" V22" 22 0)%+21& o Can9t syntesi;e car.o/yglutamyl residues for CaPP .inding o 'roduced factors are antigenically similar .ut ave a.normal CaPP .inding o -arfarin,induced s:in necrosis #ermal gangrene of te .reast" tig or .uttoc:s Rare #ue to transient y!ercoag state 0!n C<S syntesis su!!ression1 Need to .ridge warfarin wit e!arin o 3leeding 0*O !er year1 110.Contraindications to warfarin t"erapy: Fon("aindi%a(ion .e"%en( a''e%(ed Uncontrolled y!ertension 0Q)80L)00 mm?g1 )F&0 6re>uent falls or .lac:outs )E&2 2na.ility to com!ly wit treatment %&8 #aily use of NSA2#s %&2 K2 or urinary .leeding in last si/ monts )&0 B/clusion criteria used in te ma4or intervention trials of anticoagulation for !atients wit atrial fi.rillation )& 3leeding disorder or a.normal coagulation at .aseline 2& Uncontrolled y!ertension 0Q )80L)00 mm?g1 E& Active .leeding F& ?aemorragic retino!aty *& ?istory of intracranial aemorrage G& Use of non,steroidal anti,inflammatory drugs +& Cronic alcool a.use 8& Ris: of gastrointestinal .leeding 0active !e!tic ulcer disease" !ositive faecal occult .lood testing" :nown oeso!ageal varices1 %& 'lanned surgery or invasive !rocedure )0& 'regnancy or .reastfeeding Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 8% Canadian Vascular Surgery Minimum ))& 'syciatric disorder or dementia )2& B/!ected !oor com!liance )E& Aimited life e/!ectancy )F& Significant renal dysfunction 0creatinine Q 0&2* mmolLA1 )*& 'latelet count R )00 / )0%LA )G& OterC Recent stro:e or transient iscaemic attac: 0!revious two years1 'atients were also e/cluded if tey refused to !artici!ate or if teir doctor considered te ris: of anticoagulation was too great& ?armC.enefit analysis in !rescri.ing warfarinC The "is= o' maPo" b+eeding in 5a(ien( ,i(h AD ("ea(ed ,i(h ,a"'a"in- o 1/4K 5e" $ea", o ,i(h an in("a%"ania+ b+eeding "a(e o' 083/08MK 5e" $ea"& o 5e fatality rate mirrored te intracranial .leeding rate& 2n o.servational studies of am.ulatory !atients te ris: of ma4or .leeding is F,%O !er annum& Ma4or determinants of warfarin,induced .leedingC o intensity of anticoagulation" o !atient caracteristics" o te concomitant use of drugs tat interfere wit aemostasis o te lengt of tera!y Intensity of anticoagulation and duration of therapy 5e ris: of .leeding increases wen 2NR e/ceeds F&0& 2NR Q F&0 te most im!ortant ris: factor for intracranial aemorrage" inde!endent of te indication for warfarin& The "is= o' maPo" b+eeding- o g"ea(es( in (he 'i"s( mon(h o' (he"a5$ 6QK# o de%"eases ,i(h (ime (o 088K 5e" mon(h 'o" (he "emainde" o' (he 'i"s( $ea" and (o 08QK 5e" mon(h (he"ea'(e"8 A6 and ageC D"amingham s(ud$- (he in%iden%e o' s("o=e due (o AD in%"eased ,i(h age- o 18MK 'o" M0/MN $ea"s o 3Q8MK 'o" (hose aged 80/8N $ea"s8 5e !revalence of A6 in !ts 80 years old is)0O& Advanced age is not itself a contraindication to warfarin& Studies A6 su!!ort te ongoing .enefit of anticoagulation wit increasing age& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age %0 Canadian Vascular Surgery Minimum Wa"'a"in (he"a5$ "edu%es (he "is= o' is%haemi% s("o=e in 5a(ien(s ,i(h non/ "heuma(i% AD '"om L84K (o 38QK 5e" $ea"8 Age is" owever" a R6 for more unsta.le !rotrom.in time results& o 6or every )0,year increase in age tere is a )*O increase in te ris: of anticoagulation aving to .e sus!ended .ecause of a raised 2NR& tt!CLLwww&australian!rescri.er&comLmaga;ineL2+LFL88L%2L`t) 111.%"at drugs affect warfarin: o .o(en(ia(eaugmen( Allo!urinol Aminoglycoside Amiodarone Oral y!oglycemics Acetomeno!en Ci!ro Cimetidine Brytromycin 6lucona;ole 2sonia;ide Metronida;ole Ome!rasole 'enytoine 'ro!ranalol 5etracycline Alcool in liver disease Remembe" (hese- h$5og+$%emi%, Aminog+$oside, %i5"o, me("onidazo+e, ome"azo+e AHIMEJT o 9nhibi(- Anti,istamines A;atio!rine 3ar.iturates Car.ama;e!ine aldol Cyclos!orine s!ironolactone Rifam!in Sucralfate Vit I Remembe" (hese- Ha+do+, s5i"ono+a%(one, %$%+os5o"in, ba"bi(u"a(es 9JH9<9T C:@ Heparin *s $#%H: ?e!arinC F000,F0"000 #a" o !olysaccaride from !or:L.eef lung" o ow it wor:sC increases affinity of antitrom.in to trom.in < .inds trom.in directlyN inactivates !latelets& Releases 5issue 6actor 'atway ini.itor Releases endotelial 5'A o Activity vs J and 22 H )C) ratio" Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age %) Canadian Vascular Surgery Minimum o alf life G0 min" some say %0 min o cleared .y endotelium and macro!age .inding" renal if ig dose of e!arin is given" o more cance of !latelet ini.ition com!ared wit AM-?" o reversal wit !rotamine" o can .e given iv and sc" o monitor anti Ja" '55" AC5" o more .leeding and ?25 com!lications H ?25 seen in a.out *O ris: Aow Molecular -eigt ?e!arin H F000,8000 #a" en;ymatic de!olymeri;ation of U6?" activity vs J and 22 in 2,FC) ratio" li:e e!arin" releases 5issue 6actor 'atway 2ni.itor" alf life G " renal clearance" less !tt ini.ition" only sc administration" no need to monitor" less .leeding and ?25 com!lications, ?25 seen in a.out 0&*O 112.Prota!ine !ec"anis! of action: o Cation tat .inds e!arin )C) ratio o Restores A5222 to its9 inactive state 113.Direct &"ro!.in in"i.itors: Ai!irudin " Argatro.an" irudin& 2ni.it 5rom.in directly& Can9t .e reversed& Argatro.anC As: for ematology consult ?alf life H F* min" onset in E0 min" ma/ effect in ),2 ours Kive infusion of 2 mcgL:gLmin Iee! a'55 at )&*&,2&* Can9t reverse DISORDERS OF COAGULATION 114. HI&: o Q *0O !!t dro! OR !!t R)00"000 OR resistance to e!arin wit trom.otic com!lications wile on e!arin o Can .e seen as a la.oratory finding 04ust ?25 H e!arin induced trom.ocyto!enia1 or a clinical finding wit trom.osis 0?255 H e!arin induced trom.otic trom.ocyto!enia1 o 'latelet dro! in * O of !ts on e!arin for Q * dyas o Ma4ority wit ongoing e!arin use Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age %2 Canadian Vascular Surgery Minimum o More cance wit U6? ten AM-? o 5y!e ) H non immune related" inconse>uential o 5y!e 2 H 2g K vs '6F o #sC !latelet aggregation" serotonin release assay" BA2SA 0for 2g K and '6F,e!arin com!le/1 o Alternative to e!arinC le!irudin" argotro.an" dana!aroid& 115. Hypercoagula.le state: o ?ig ris: of trom.osisC Antitrom.in deficiency 'n C< S def ?25 Anti!os!oli!id o Aower ris: of trom.osisC 6actor V Aeiden ?y!eromocystenemia 'rotrom.in 202)0 !olymor!ysm Ano(he" ,a$ (o %+assi'$ h$5e"%oagu+ab+e s(a(e- A"(e"ia+- 'latelet a.normalities y!erfi.rinogenemia li!o!rotein 0a1 aterosclerosis <)TH &enous and a"(e"ia+- y!eromocysteinemia ?25 elevated 'A2,) anti!os!oli!id A3C o cardioli!inLlu!us anticoagulant Genous- 6actor V leiden !n 202)0 A !olymo!ysm !n C < S antitrom.in dysfi.rinogenemia Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age %E Canadian Vascular Surgery Minimum 116. Antip"osp"olipid anti.odies: )$AC/ AC$ and S$: o 2K directed vs !os!oli!ids o 6amily of !ns" one of tem is AB 0lu!us anticoagulant1 o 5ey ave .ot !ro coagulant and anticoagulant activity , 2n vitro" tey !revent coagulation factors from interacting" slowing coagulation 0'55 !rolongation1 2n vivo H tey do not ini.it any coagulation activity" .ut encourage it troug !oorly understood mecanisms H endotelial damage" ini.ition of !rostocyclin secretion" interference wit fi.rinolysis& o SAB can .e associate wit Systemic arterialLvenous trom.osis Recurrent a.ortion Neurologic disease o Au!us anticoagulant < anticardioli!in anti.ody seen in association wit SABC LAF 2 Q4K 6&s 3K in gene"a+ 5o5u+a(ion# o A 'o+d "is= o' DGT AFL 2 44K 6&s u5 (o LK in gene"a+ 5o5u+a(ion# o 3 'o+d "is= o' DGT o Ris: of arterial trom.osis is 2*O&&& 117. Resistance to acti*ated factor -: o Most common a.normality associated wit V5B o Resistance to inactivation of factor V .y activated !rotein C o ?ence" activation of 22 is not ini.ited o Clinical effects de!end on weter two 0omo1 or one 0etero;ygous1 co!ies of te mutated gene are !resent ?eterogenous H + fold increase of trom.osis" omo H 80 fold
118. Causes of !esenteric t"ro!.osis: 2dio!atic H most common ?y!ercoag state 0deydration aggravates tis1 Venous congenstion o C?6 o !ortal y!ertension in4uryC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age %F Canadian Vascular Surgery Minimum o trauma o !ost surgery o inflammation 023#" !ancreatic1 o infection 0se!sis" a.scess" !eritonitis1 CD@ Co!!on ac2uired causes of .leeding and t"eir treat!ent: o ?e!arin use H anti 22 via A5 222" 56'2" t!a" !latelets elevated '5L'55LAC5" use !rotamine o Argatro.anLirudin H direct anti 22" ig '5L'55" use 66' o warfarin" liver failure" malnutrition" .iliary o.structionC lac: of J" 2J" V22" 22 0)%+21 elevated '5 only use 66'Lvit I" octa!le/ o dilution fewer molecules or cell mem.ranes around re!lace missing su.stances o .one marrow failure trom.ocyto!enia 2# .y .one marrow ./ !latelet transfusion o acidosisLy!otermia diminised en;ymeL!latelet function correct causeLwarm u! Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age %* Canadian Vascular Surgery Minimum o #2C Klo.al activation of entire clotting Consum!tive coagulo!aty Correct cause" re!lace factors #o NO5 give antifi.rionlytics o 5rom.olytic tera!y Reduced fi.rinogen" clot lysis Blevated 6#'" BCA5 Kive cryo!reci!itate o 'rimary fi.rinolysis Reduced fi.rinogen" clost lysis Blevated 6#'" BCA5 Kive antifi.rinolytics 0gamma amino ca!roic acid1 o Uremia 2m!aired !lateletLendotelium function Aengtened .leeding time d#AV' o as!rinLK' 22.L222a use !ermanent !latelet dysfunction lengtened 3leeding time !latelet transfusion o s!ecific ini.itor antifactor" usually V222 seen as resistance to factor re!lacement give iger dose" immunosu!!ression THROMBOLYSIS 119.&ypes of t"ro!.olytics: Stre!to:inase H rarely used" does not directly activates !lasminogen" need to form activator com!le/ first& Uro:inaseC directly activates !lasminogen H .ot circulating AN# .ound to fi.rin o C#5 wit infusion witin te trom.us o #oseC 2*0"000 2U lacing .olus s!rayed into clot ten infusion F000 2ULmin fo F " ten 2000 2ULmin for u! to EG o Re,evaluated !ts at G,)2 ours t'A H activates fi.rin .ound !lasminogen ONA= tus limiting systemic effects Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age %G Canadian Vascular Surgery Minimum o C#5 o loading dose is 2,* mg May give u! to E times at *,)0 min interval" ten infusion at 0&0* mgL:gL H i&e& E&* mgL for +0 :g !t& o 6or all trom.olytics monitor fi.rinogen o Com!lication of trom.olysisC !uncture site emorrage distal em.oli;ation !ericateter trom.osis intracranial emorrage 0R) O1 alte!lase H li:e t'A" .ut iger affinity for fi.rin and longer alf,life 120. Contraindications to t"ro!.olysis: o A.solute CV event 0including 52A1 in !ast 2 monts 2ntracranial trauma 0e&g& neurosurgery1 in !ast E monts active .leeding K2 .leed in !ast )0 days o Relative ma4or 5rauma < surgeryC o ma4or non,vascular trauma or surgery in !ast )0 days o C'R in !ast )0 days o recent eye surgery o !uncture of uncom!ressi.le vessel uncontrolled ?5N 0Q)80L))01 2C tumor o Relative minor e!atic failure wit coagulo!aty .acterial endocarditis !regnancy dia.etic emorragic retino!aty 121.&"ro!.olysis studies su!!ary: Rocester trialC surgery vs trom.olysis ))F !t randomi;ed Same lim. salvage at ) mont Same survival at E0 days .ut worse survival for surgery at ) year Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age %+ Canadian Vascular Surgery Minimum S52AB trialC surgery vs trom.olysis for iscemic AB& 2nitially !ts were not randomi;ed according to duration of iscemia all analysis was done after te trial was com!leted on su.sets of !t !o!ulation o ence" source of .iasM o Acute 0R)F days since onset1 at E0 days Overall" no difference" e7%e5( need 'o" am5u(a(ion a'(e" 'ai+u"e o' su"ge"$ Surgery ad more am!utation .ut it is non,significantM Aysis Surgery Am!utation GO )+O 'U0&0G" NS Am5 a'(e" 'ai+u"e Q0K A8K 'U0&0) 3leeding GO 0O Mortality *O *O o Cronic 0Q)F days since onset1 at E0 days Same mortality 0FO1 and am!tation 0FO1 Do" &e"$ high "is= 5(s, su"&i&a+ a( 1 $ea" ,as be((e" in +$sis %om5a"ed (o su"ge"$ 6LK &s Q3K# o Native vesselsC 2E+ !ts Aess am!utation and iscemia at ) year wit surgery Aysis Surgery 2scemia @ ) year GFO E*O Am!utation @ ) year )0O 0O o 'rosteticC AcuteC lysis .etter tan surgery Aysis Surgery Am!utation )year 20O F8O CronicC o Same rates of am!utation for surgery and lysis o 5o!a;C #o;e !ase H F000 uLmin followed .y M RC5C same lim. salvage" same survival" less surgery in trom.olytic grou! Th"ombo+$sis ("ia+s %on%+usion- o ) year mortality is )0,20O Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age %8 Canadian Vascular Surgery Minimum o Aysis as intracranial .leeding rate of u! to 2O" All .leeding com!lications , *O -it t'A lessM o 9n a%u(e se((ing &s %h"oni% se((ing, +$sis is eBui&a+en( (o su"ge"$ ,"( mo"(a+i($ and +imb sa+&age ,i(h se&e"a+ %a&ea(s- o L$sis has ad&an(age- 2n acute setting" less am!utations if !rocedure fails .etter for !rostetic occlusion 2n cronic settingC May ave long term advantage for very ig ris: !ts o Ja(i&e a"(e"$ (h"ombosis is be((e" add"essed (h"ough su"ge"$
6or vein grarts" .est results wit trom.olytics are acieved for !ts witout #M and in late failures as o!!osed to early& 3ecause trom.olysis trials did not demonstrate SU'BR2OR25= of trom.olysis" it is not clear wic metods sould !referentially .e used in AA2& Overall" in !ractice surgery is !referred& 122.Intraoperati*e t"ro!.olysis: "ow to? o 2m!ortant !art of trom.ectomy o Camerota RC5 of uro:inase sowed tat intrao! route is safe" no !lasminogen de!letion" and lower mortality com!ared to !lace.o o After trom.ectomy is done H do angio& o 2f clot is gone H occlude artery and .olus 2A lytic in distal .ed 2,8 mg t'A or )00"000,2*0"000 uro:inase o 2ncom!lete trom.us H eiter re!eat .olus or restore !erfusion and start 2A dri! wit cateter o B/tensive residual trom.us H 2solated lim! !erfusion B/sanguinate lim. 2*0 mm .lood !ressure cuff to tig Canulate !o! vein wit red ru..er cat Canulate A5 and 5'5 2nfuse *00"000 uro or *0 mg t!a into eac artery in *00 cc of NS over 20 min #rain vein" flus out wit anoter ) A NSLe!arin Restore circulation Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age %% Canadian Vascular Surgery Minimum Can :ee! cuff for u! to ) Most of !lasminogen activator esca!es via vein& Some will go into .one marrow ,Qsystemic Angio4et C o Reduced incidence of distal em.olisation o No !ros!ective study surgery vs mecanical device is availa.le o Retros!ective studyC o .etter survival" .etter !atency" same am! free survival angio4et Surgery FL)2 !atency +8O G+O !U0&0)+ GL)2 survival 88O +*O !U0&02 Am! free survival )2L)2 ++O G)O !U0&0+ DVT 123.Diagnostic criteria for D-&: CD1? Acute H less tan 2 wee:s Su.acute H .etween 2 wee:s and G monts Cronic H more tan G monts C UVenous incom!ressi.ility o Most im!ortant criterion" te rest are su!!ortive #U distended large vein in ACU5B setting o 5rom.us visuali;ation H ecolucent o Vein is contracted and clot is eterogenious in C?RON2C #Vt 6UA.sent or diminised s!ontaneous flow o A.sence of res!iratory !asicity ins!iration augments UB flow" decreases AB o A.sent or incom!lete color filling of lumen AdditionalC Com!are wit contralateral side R*0O diameter increase wit Valsalva 0i&e& no res!onse to !ro/imal o.struction1 immo.ile venous valves 124. R1 and outco!es for D-&: 80O of 'B are clinically silent Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )00 Canadian Vascular Surgery Minimum VS as ig false !ositive rate RuterfordC #V5 H seen in 20O of !ts undergoing Ken surgical !rocedure 6atal 'BC Ken surgery H 0&+O witout !ro!yla/is o #own to 0&)O wit e!arin Blective i! H 2,EO ?i! fracture H F,+O Ruterford !& 2)EG After #V5" veins -2AA recanali;e Rate and recurrence of #V5 will determine via.ility of valves o And incidence of CV2 and '5S 2n 2LE" valves will .e damaged and will lead to !ost,trom.otic se>uellae ?istological evidenceC o 5rom.us organi;ation rarely involves valve cus! o Clear ;one around valve due to endotelial fi.rinolytic activity 2* year study of MorC )*00 !ts 5ime CV2 incidence ) +O * )FO )0 20O 20 2*O Venous Ulcers at 20 years Sur!ising EO ?owever" !ro/imal o.struction will increase ris: of CV2 %*O of !ts wit iliofemoral trom.osis treated .y AC alone ave am.ulatory venous y!ertension at * years o %0O ave sym!toms of CV2 o )*O ave ulcers o )*O de.ilitating venous claudication Argument to clear iliofemoral clot .urden o Biter wit C#5 or o!en trom.ectomy o See iliofemoral trom.osis notes RD 'o" DGT- o Age C F0 yoa o 2mmo.ility os!itali;ation Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )0) Canadian Vascular Surgery Minimum neurologicL!aralysis travel o 5rauma surgery H de!ending on ty!e o neuroLortoQ generalQBN5 trauma o Venous tn C?6 venous insufficiency o ?y!ercoagula.le state OC' fam / see ?CS malignancy !regnancy o Systemic inflammatory state SAB 23# Lo, "is= )1 R 40 yrs age 3# Jone o' (he "is= 'a%(o"s +is(ed E1 Keneral anestesia for R Q0 minu(es F1 Minor elective" a.dominal" or toracic surgery& -itout !ro!yla/is !ro/imal DGT "is= R 180 K 6atal 'B R 0&0) O 'ro!yla/is , ea"+$ ambu+a(ion Mode"a(e "is= )1 > 40 yrs 21 Keneral anestesia > Q0 minu(es E1 ) or more ris: factors DGT 3 / 10 K 6atal 'B 0&) , 0&+ O 'ro!yla/is H A#U? *000u 3id or 5id" )R intermittent com!ression until am.ulation High "is= Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )02 Canadian Vascular Surgery Minimum )1 > 40 years 21 Surgery for ma+ignan%$ or an o"(ho5edi% 5"o%edu"e E1 Keneral anestesia Q E0 minutes F1 ?ave an inhibi(o" de'i%ien%$ s(a(e or o(he" "is= 'a%(o"s 'ro/imal #V5 10 / 30 K 6atal 'B )&0 , *&0 O 'ro!yla/is H LMWH od AJD 2C until am.ulation #r& -ells 0University of Ottawa1" et alC Aancet )%%+N E*0C )+%*,)+%8 active cancer 0ongoing treatmentLdiagnosed witin G monts or !alliative care1, score ) !aresis" !aralysis or recent !laster cast immo.ilisation of lower e/tremity, score ) recently .edridden for more tan E days andLor ma4or surgery witin F wee:s, score ) localised tenderness over distri.ution of dee! veins, score) entire leg swollen, score) calf swelling more tan E cm com!ared wit asym!tomatic side" measured at )0 cm .elow ti.ial tu.ercle, score ) !itting oedema 0greater in sym!tomatic leg1, score ) collateral su!erficial veins 0non,varicose1, score ) alternative diagnosis as li:ely or greater tan tat of #V5, score SU35RAC5 2 2n !atients wit sym!toms in .ot legs" te most sym!tomatic leg is used score 0 or less, low ris: 0EO !ro.a.ility #V51 score ) or 2, moderate ris: 0)+O !ro.a.ility #V51 score E or more, ig ris: 0+*O !ro.a.ility #V51 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )0E Canadian Vascular Surgery Minimum 125.D)di!er in diagosis of D-&: o Measure #,dimer in out!atients wit low !retest clinical !ro.a.ility o 'roduct of fi.rin degradation Aow !retest !ro.a.ility ris: !ts H N'V %%O" ig !retest !ro.a.ility ris: !atients H N'V E*O o 2f !retest !ro.a.ility is low" order #,dimer& 2f it9s low" you9ve ruled out #V5 o 2f 'retest 'ro. or #,#imer is ig H need to order du!le/ One negative du!le/ rules out #V5 Cost of first follow u! du!le/ is E%0"000a !er life saved Cost of second follow u! du!le/ is E&* mln a !er life saved 126.%ays to treat D-&: o BlevationL.ed rest PL, AC o AC alone Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )0F Canadian Vascular Surgery Minimum o AC P 2VC interru!tion 0filter1 o C#5 -ill decrease !ost trom.otic se>uellae of iliofemoral dvt" NO5 fem,!o! 0large venous registry1 2 small RC5 did not sow difference wit AC for fem,!o! Kreat for acute #V5 0R)0 days1 Aarge R5C is needed H !ending 5OAB#O 2f fails H 'C mecanical trom.ectomy o Surgical trom.ectomy , for 2A2O6BMORAA #V5 6or active am.ulatory !ts OR (o 5"e&en( venous gangrene in !alliative !t Swedis RC5 H )0 year !atency 80O vs E0 O 0AC alone1 Muc .etter !atency and valve function com!ared to AC alone o Surgical .y!ass if 2VCL2liac occlusion AN# s/s 5reatmentC ?e!arin,Qwarfarin Bno/o!arin 0)mgL:g .id or )&*mgL:g od1,Qwarfarin ?ow longC A.ove :nee #V5" no 'B H o E monts treatment o Blevate leg" com!ression ose" may return to wor: in 2 wee:s o #u!le/ at +2" ) mont" G monts o Multi!le follow u! du!le/ is NO5 cost effectiveM A.ove :nee #V5 wit 'B or recurrentC o G mont treatment o E rd e!isode H life time AC 3elow :nee #V5 H some say follow wit #u!le/" some say treatM 29d treat for fear of 20O !rogression& Alternatively" may follow wit serial #o!!ler US in ) wee:& 5e only #V5 tat is safe not to treat is tat of soleal sinuses and o.serve Most common vein to trom.ose H !eroneal" least common H anterior ti.ial& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )0* Canadian Vascular Surgery Minimum 127.Indications for I-C filter: o A.soluteC Need to anticoagulate .ut !t as contraindications Need to anticoagulate .ut develo!ed com!lications wit AC 'ost !ulmonary em.olectomy !rev caval interru!tion 0ligation or filter1 failed o RelativeC 6loating 2liofem trom.us 'ro!agating iliofemoral trom.us wile on AC Se!tic 'B Cronic 'B in !t wit 'ulmonary y!ertension and core !ulmonale 't wit Q *0O !ulm vessel occlusion wo can9t afford to lose more !ulm function wit recurrent !ulmonary em. ig ris: of falls H as in severe ata/ia 0can9t anticoagulate1 asideC 'RB'2C F00 !t wit !ro/imal #V5 All are AC9d" alf ave 2VC filter !ut in At )2 days more 'B in non 2VC grou! FO vs )O ?owever" tere was NO difference in Mor.idity or mortality related to 'B at 2 years 5ere is increased ris: of su.se>uent #V5 if ave 2VC filter in !lace o )0O vs 20O o Still" no role for !ro!ylactic anticoagulation if ave filter in !lace Are 2VC filters all5?A5 necessaryD ?ence argument for retrieva.le filterM 5em!orary filter H ave wireLseat attacment Retrieva.le filter H li:e regular filter .ut can .e removed at a later date Cancer !ts ave very ig rate of #V5 and 'B 128.Co!plications of I-C filter: o @ !lacementC Access .leedingLarterial in4uryL!seudoaneurysm 2VCLSVC in4ury 2ncom!lete de!loyment Mis!lacement Renal contrast load o -ile in !laceC Migration O.struction wit clot 2nfection Recurrent 'B Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )0G Canadian Vascular Surgery Minimum o @ removalC Access .leedingLarterial in4uryL!seudoaneurysm 6ailure to retrieve Renal contrast load in4ury to SVCL2VC 129.#igratory p"le.itis: Seen in !ancreatic ca" .uerger disease" .ecet9s disease" 'AN& Su!erficial !le.itis as 20O ris: of 'B H NO5 a .enign entity 130.ffort t"ro!.osis: classify 6re>uencyC o 'rimary H effort H 2*O o Secondary H Central lines F0O" infection" !rev #V5" UB AV6" y!ercoag state" trauma H E*O !atC venous ?5N" related to o.struction" rater tan reflu/ AC ma:es no difference on degree of disa.ility 'B incidence H +O o 'rimary H Sometimes see anatomic defect in 5O young males dominant e/tremity in +*O +*O re!ort strenuous re!eated activity !rior to onset o Secondary H CV cateter MC" malignancy" infection" trauma" trom.ocytosis to treat" 4ust remove cateter" consider AC onlyM 131.&reat!ent options for pri!ary axillary *ein t"ro!.osis: )bse"&ee+e&a(eAF vs in(e"&ene T"ea(men( o5(ions 'o" 5"ima"$ a7i++a"$ &ein (h"ombosis- )& AC" and wait for te clot to go away" vein to recanali;e 2& Cateter #irected 5rom.olysis" to actively o!en u! vein E& 5oracic outlet decom!ression if e/ternal com!ression demonstrated" F& O!en Angio!lasty vs stent for intrinsic residual stenosis in te vein" *& surgical .y!ass for failed trom.olysis AN# disa.ling sym!toms& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )0+ Canadian Vascular Surgery Minimum Confusion and variation .egin wen you factor in timing and order of tese interventionsM ?ere is te a.ove list wit timing considerationsC A8 F)J;ERGAT9GE a55"oa%h- Arm BlevationLRest alone not !ractical for most active !atients for ig ris: only wit minimal function and AC Contraindications An(i%oagu+a(iona"m e+e&a(ion"es( a+one ."e'e""ed a55"oa%h o' mos( o' %onse"&a(i&e hema(o+ogis(s .oo" 'un%(iona+ "esu+(s a%%o"ding (o Ru(he"'o"d: 'lease note" tat AC alone ma:es no difference on degree of future disa.ility H i&e& it does not im!rove function muc& 'B incidence H +O <8 9JTERGEJT9)JAL a55"oa%h- o!en u! vein wit C#5 0most commonly1 vs o!en surgical 0not common as a stand alone H unless com.ine wit immediate 5O# and o!en veno!lasty1 0ues(ions a"ise as (o WHEJ (o do T)D i' su%h is diagnosed- o!en u! vein wit C#5 andLOR anticoagulate for E monts" ten venogram i' e7(e"na+ %om5"ession a+one, (hen T)D8 Mos( %ommon s%ena"io8 2f internal defect alone" o!en veno!lasty vs .alloonLstent if normal venogram H E monts of ACLABLR& o Aeast common scenario& o 5en decide on sto!!ing AC vs continuingM AdPun%(s 'o" &ein de'e%(s- for sort stenotic segment a& o!en veno!lasty .& endovascular !lasty PL, stenting for long stenotic segment a& trial of ACLABLR& 2f fail" ten consider venous .y!ass or 2$ turndown 5O#C On e/am" (he %+assi% ans,e" ,ou+d be (o +$se 6i' no %on("aindi%a(ions#, =ee5 AF 'o" Q mon(hs, (hen b"ing 'o" de+a$ed T)D i' indi%a(ed b$ &enog"am8 MAIB sure you let te !t coose and review com!lications of trom.olysis 02C emorrage1 as well as contraindications to trom.olysis& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )08 Canadian Vascular Surgery Minimum 132.Iliofe!oral -enous t"ro!.osis: o Aggressive a!!roac H ig rate of sig !ost trom.otic se>uellae tat are difficult to manage conservatively early relief of o.struction may !revent suc se>uellae& 'legmasia cerulean dollens H o.struction of AAA venous outflow& 'legmasia al.a dollens H o.struction of only MA$OR venous outflow" wit !atent su!erficial outflow& o Al.a H .ecause of concomitant arterial vasos!asm& o 2liofemoral trom.ectomyC anticoagulate C5 first to assess caval involvement PL, 2VC filter KA" )0 mm 'BB' to decrease 'B cance 6ascitomy first if !legmasia cerulean dollens KSV 4unction dissection" C6V to inguinal lig Aongitudinal venotomy of C6V 6ogarty !ro/imal" esmar: distal e/tremity KSV to S6A anastomosis" close in G wee:s o #iameter fistulaLartery ratio )LE o No more ten E00 mlLmin flow Com!letion venogram H A MUS5 o 2f iliac v& stenosis H !lastyLstent Iee! anticoagulated CHRONIC VENOUS INSUFFICIENCY 133.-enous flow c"aracteristics: !asic o if continuous sus!ect !ro/imal o.struction o if !ulsatile sus!ect AV6 or 6luid overload 0R C?6" venous ?5N1 unidirectional s!ontaneous res!onds to ins!iration and e/!irationLValsalva Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )0% Canadian Vascular Surgery Minimum o U!!er e/tremityC U' wit ins!iration and #O-N wit e/!iration i&e& augmented .y negative !ressure of te cest o Aower e/tremityC #O-N wit ins!iration and U' wit e/!iration i&e& augmented .y negative !ressure in te a.domen 134.Deter!inants of *enous flow: 6rom distal to !ro/imalM o Arterial inflow o 3ody !osition o Calf muscle activity o valves o 'eri!eral resistance o A.undance of collaterals o 2ntraa.odminal and intratoracic !ressure 'ase of res!iratory cycle o R eart !ressure 135.Cause of C"ronic *enous insufficiency: o Venous stasis #ue to valveLendotelial damage" stasis leads to nutritional de!rivation of s:inLtissue& ?owever" no canges in O2 sat sownM o AV fistula teory ?y!otesi;ed arteriovenous connections 2ncreased sunted flow Not confirmed o.4ectively Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age ))0 Canadian Vascular Surgery Minimum o 6i.rin cuffC diffusion .loc: Cuff on !reca!illary vessels" acting as diffusion .arrier& Not true o Aeu:ocyte tra!!ingC Acce!ted teory& Activation of neutro!ils in venous microcirculation& o leads to degranulation" endotelial damage& affects diffusion of nutrient and o/ygen" results in ulcers and s:in damage& 136.%a*e for!s of *enous plet"ys!ograp"y in se*ere S18 reflux: Am.ulatory venous !ressureC o AV' H !ressure in te dorsal !edal vein after )0 calf contractions RF0 H low ris: of ulcer Q80 H 80O cance of ulceration Return to .aseline in Normal sould .e Q E0 sec i&e& #BAA=B# refilling is NORMAA o ''K and A'K are non,invasive su.stitutes of AV' 'oto!letysmogra!yC 3 H a.normal" VR5 0venous refilling time1 is sort C H normal 3aseline H !t standing" followed .y )0 ti!,toe calf contractions H o em!ties te leg vein return of venous .lood is documented o eiter .y strain,gauge o !oto!letysmogra!yM Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age ))) Canadian Vascular Surgery Minimum 'oto 'letysmogra!y H ''K uses a transducer tat emits infrared ligt from a ligt,emitting diode into te dermis& 5e .ac:scattered ligt is measured .y an ad4acent !otodetector o dis!layed as a line tracing& As .lood fills in" it a.sor.s te ligt o 5is returns curve to .aselineM o 5e faster te !ooling" te faster te return to .aseline Ra!id return to .aseline is caracteristic of venous insufficiency& Air !letysmogra!yC Unli:e ''K" it sam!les large calf volume& Air !letysmogra! data o.tained from tracings& VV" venous volumeN V62" venous filling inde/N B6" e4ection fractionN RV6" residual volume fractionN BV" e4ected volumeN RV" residual volumeN V65" venous filling time& Aie down" ten stand u!" ten em!ty veins wit single contraction 0B61" ten em!ty veins wit multi!le contractions& Normal VV is 80,)*0 ml Residual volume is RE*O Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age ))2 Canadian Vascular Surgery Minimum GD9 / R 3 m+se%, o i' "e'+u7 i( is > Q0 m+se% Siebe+ sa$s L m+se% o i&e& curve is stee!er wit CV2 B6 H e4ection fraction H after single ti!,toe H no"ma+ > A0K Some use 52MB to refill alone H shou+d be +ess (han 3M se% (o diagnose insu''i%ien%$ Note " do not confuse V62 0normal R E0 mlLsec" some say 20M1 and time to return to .aseline 0normal Q E0 sec1 Can9t do 'K on !ts wo can9t stand unassisted or can9t do ti!toe& #u!le/ of S6$ reflu/C #o su!ine e/am for #V5 May do Valsalva H less tan 2 sec reversal of flow at S6$ sould .e seen wen !t su!ine Stand u!" cuff to lower tig" #o!!ler at S6$ 2nflate cuff" noting disa!!earance of !rograde flow Ra!idly deflate cuff H noting reversal of flow at S6$& N R0&* sec of reflu/" if more H reflu/& 137.-enous disease assess!ent: CAP classification Venous y!ertension causes e/travastion of al.umin and R3C& o R3C can9t re,enter circulation H .rea: down and !roducts of teir decom!osion stimulate vicious inflammatory reaction& o -3C migrate in o troug 5K6,b,)" fi.ro.last creat intense fi.rotic reaction H UN2SUB to CV2& 2n te end" fi.rosed inverted .ottle nec: legs are formed& Varicous veins H wit venous ?5N" SMC transform form contractile to secrotory su.ty!e& 5raditional tin:ing H o !rimary CV2 H tic:ened vein" normal valve o Secondary CV2 H tic:ened valve" normal vein o 2n reality" see elements of .ot , i&e& .ot vein and valve may .e a.normalM o C H clinical signs" add A 0asym!tomatic1 or S 0sym!tomatic1 )& 5elagectasia" reticular veins" malelar flair& #iameter R E mm 5ese do not need du!le/ study 2& Varicose veins H i&e& diameter Q E mm 5ese need du!le/ study E& Bdema" no oter canges F& ;=in %hanges 2 5igmen(a(ion, +i5ode"ma(os%+e"osis Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age ))E Canadian Vascular Surgery Minimum *& S:in canges P ealed ulcers G& S:in canges P active ulcers o B H etiology C H congenital" since .irt ' H !rimary" idio!atic S H secondary o A H anatomy S H su!erficial # H dee! ' H !erforators o ' H !ato!ysiology R H reflu/ O, o.struction R"O H .ot Venous clinical severity scoreC validated E0 !oint tool to assess disease& 138.Approac" to *enous ulcers: o Confirm venous etiology ?istoryLe/amLdu!le/ H KSVLdee!L!erf incom!etence On /C Varicosity 0since .irt vs BVBN51 #V5L!regnancyLvein t/Larvest Occu!ation OC'Lfam / Race o African American H !erimalelar ulcer H tin: sic:le cell o RLo arterialLneuro!aticLinfection contri.ution o ?eal ulcer conservatively Blevation" Com!ression" infection treatment o 2f does not eal after E monts" rLo malignancy and consider an intervention 2ndication .leeding 'ain o Acing !ain o Aeg eaviness o Basy leg fatigue Su!erficial trom.o!le.itis cosmesis CBA' F , G o Ulcer o B/ternal .leeding o An:le y!er!igmentation Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age ))F Canadian Vascular Surgery Minimum o Ai!odermatosclerosis o S:in atro!y Expanded Aside: Classify varicosities H congenital" !rimary 0underlying structural !ro.lem1" secondary
#istinguis !rimary from secondary varicositiesC 'rimaryC early onset" fam / of varicosities& 'reci!itatitng factorsC after !regnancy" e/ternal com!ression 0may turner" !elvic mass1& SecondaryC will ave / of normal lim." ten #2S52NC5 event 0#V5LtraumaLiatrogenic surgery1" y!ercoagula.le stateLfam / of suc" contrace!tive use" AV fistula& ?istory sould always includeC !rofessionLlong u!rigt standing& Review !revious ulcerLvein surgeryLtreatment o com!liance and wor: u!& istory of vein arvest" #V5 !regnancy" y!ercoagula.ility" trauma avf / of 2CLrest !ain R6 for Ateroscelrosis as te ulcers will turn out to .e mi/ed in origin o smo:ing" tn" l" omo" dm" cvaLmi os!ital admission AsideC Classify varicosities H congenital" !rimary 0underlying structural !ro.lem1" secondary Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age ))* Canadian Vascular Surgery Minimum
#istinguis !rimary from secondary varicositiesC 'rimaryC early onset" fam / of varicosities& 'reci!itatitng factorsC after !regnancy" e/ternal com!ression 0may turner" !elvic mass1& SecondaryC will ave / of normal lim." ten #2S52NC5 event 0#V5LtraumaLiatrogenic !rocedureLsurgery1" y!ercoagula.le stateLfam / of suc" contrace!tive use" AV fistula&
On e/amC -it !rimary" li:ely see S6$ involvement only" i&e& !redominantly su!erficial reflu/ o i&e& no !erfLdee! vein !ro.lems o less remar:a.le CV2 stigmata& Secondary will ave more advanced disease o #ee! refulu/" !erforators" significant CV2 stigmata ins!ect H o swelling" vari/" ulcer , veinC !in:" clean .ottom" flus wit s:in level" moderately tender to !ainless" .etter wit elevation" .leeds on !ro.ing" gaitor area" o normal !ulses" o signs of CV2 telangecatsiaLreticular 0)1" varicose 021" swelling 0E1" s:in canges , atro!y .lance" li!odermatoscleoris 0F1" ealed ulcer 0*1" active ulcer 0G1& AsideC o Arterial ulcer , !ale fi.rinous necrotic .ottom" distal foot" !ainful" !unced out" !oor !ulses" .etter wit de!endency" signs of 'A# and R6 on istory !lus 2CLrest !ain& B/am cont9d auscultateC .ruit for 'A# !al!ateC 5rendelen.erg" !ulses Asses reflu/ in su!erficial and dee! system and !erforators& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age ))G Canadian Vascular Surgery Minimum 5rendelen.erg test H su!ine" elevate leg" com!ress KSV 4unction or ASV 4unction& Stand u!" maintain com!ressionC o watc fast refilling of vein from .elow H cec: !erforators Release com!ression H o see fast refilling from a.ove H cec: in line valve insufficiency 6inally" investigationsC #u!le/ 6irst cec: for #V5 wen su!ine" and Q 2 sec reflu/ at S6$ wit valsalva U!rigt H cec: for Q0&* sec reflu/ wit cuff deflation distal to S6$ Venogra!y H rarely )st Ascending for o.struction #escending for reflu/ 'ressure gradient studies if sus!ect o.struction A32 PL, angio if necessary C5LMR2 if sus!ect central o.struction Ambu+a(o"$ &enous 5"essu"e- o 'ressure in te dorsal !edal vein after )0 conse>uitive calf contractions& o Sould di! from 80 mm ?g standing to 20,E0 mm& 2f going u! H sus!ect !ro/imal o.struction o Sould ta:e E0 sec or more to return to 80 mm wit standing >uietlyC 2f faster H sus!ect valve incom!etence ''K and A'K are non,invasive su.stitute for invasive AV' measurement& Fonse"&a(i&e ("ea(men(- Com!ression #ressing cange H #R= gause Blevation ASALiodosor.L!ento/ifyllineL'rostoglandin o !& 22F*,F+ o NO occlusive ydrocolloid dressings 0duoderm1 same ealing rates as dry" may .e more infection Com!ressionC RuterfordC E0,F0 mm ?g .elow :nee Sigvaries recommends te following C2C Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age ))+ Canadian Vascular Surgery Minimum Abso+u(e %on("aindi%a(ions- Advanced !eri!eral o.structive arterial disease Severe neuro!aty 0dia.etic1 Congestive eart failure 0active1 Se!tic !le.itis 'legmasia coerulea dolens Una.oot H glycerin" ;n o/ide" camomile" sor.itol" mg" al silicilate 2f mi/ed ulcer in old gentleman and A32 0&G , may try ligt !rofore dressing for E,F wee:s 9' no( im5"o&ing / "e&ie, diagnosis- rLo non,com!liance mimic:ersC o C5# o ?5N o Malignancy o 'yoderma gangrenosum o Calcifila/is in dialysis !atients local and general factors !reventing ealingC o infection rLo osteomyeltis and w<w infections o ongoing trauma o stalled wound need for de.ridement" needs growt factors o malnutrition o immunocom!romised state malnourised cancer cemo Fonside" adPun%(s ,
intermittent com!ression !romogranLregrene/L!latelet s!in,off to :ic: start stalled wound a./ ivL!o if cellulitis antimicro.ial in te wound consider y!er.aric o/ygen consider a!ligrafL!ento/yfilin" ilo!rost
Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age ))8 Canadian Vascular Surgery Minimum 2f surgery necessary H consider location and see if stri!!ing KSVLligation would el!& 9ndi%a(ion 'o" su"gi%a+ in(e"&en(ion- after E monts of intensive com!liant conservative managementM )& ulcer 2& !ain E& .leeding F& su!erficial trom.o!le.itis and trom.osis of KSV *& cosmetic ?ealed ulcer is not li:ely to o!en u! again& ?owever" wit maintenance !rogram" E0O recurrence is e/!ected& 2f no maintenance is adered to" )00O recurrence is guaranteed& Overall" GO of !ts wit CV2 will !rogress to ulcer over * years 0Minessota study1& 139.(a!e *eins ligated during sap"enous *ein stripping: su!erficial e!igastric su!erficial circumfle/ iliac su!erficial e/ternal !udental o tese may .e left intact if you .elieve in neovasculari;ation o Ruterford doesM greater sa!enous anterior accessory !osterior accessory 140.%"y does *ein stripping surgery fail: Surgical errorC failure to remove te KSV from te circulation o Aigated S6$ only" not stri!!ed o Missed du!licated sa!enous vein o mistoo: accessory sa!enous vein for te KSV Non,sa!enouse source of venous ?5NC o !erforating veins wit incom!etent valves genetic tendency to form varicosities neovasculari;ation asideC contrary to !revious dogma" Ruterford !oints out tat leaving some .rances intact actually !rotects from neovasculari;ationM So it !ays to .e 7slo!!y8 141.-enous claudication: cause o 3ursting dee! leg !ain wit e/ercise o 'ro/imal venous o.struction" distal veins are usually normal Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age ))% Canadian Vascular Surgery Minimum o #ue to e/ercise induced y!eremia AN# increased venous outflow resistance& 142.C"ronic I-C=iliac=deep *ein o.struction: o 2ntrinsic venous defectC Acute #V5 Bndotelial scarringC 'ost cronic #V5 Radiation A.normal venous we.s" y!o!lasia" a!lasia o B/ternal com!ression Retro!eritoneal fi.rosis 3enignLmalignant tumor Cyst Aneurysm 0arterial1 3andsLsli!s May 5urner syndrome 0A common iliac vein com!ressed .y R C2A1 5estingC #u!le/ 'letysmogra!y C5LMR2 a.domen Resting armLfoot venous !ressure difference Q F mm ?g Resting su!ine centralLfemoral !ressure difference Q * mm ?g 2 fold increase in femoral !ressure after e/ercise o )0 dorsifle/ions at an:les o 20 isometric calf contractions Venogra!y H ascending X o for OR !lanning o 3Ll femoral vein !uncture Venous stentC Kianturco Y stentC self,e/!anding" 8,F0 mm" good loo! strengt" no forsortening" can use across tri.utaries 0renal vein1 H i&e& large cells 143.S-C o.struction: 3lindness and cere.ral emorrage is an uncommon com!lication& CauseC Cancer 0lung" mediastinal AN" tumors1 H 8*O 3enign H o MOS5 Common H mediastinal fi.rosis" o =atrogenic H due to cateters 5reatmentC o 2f Cancer H radiation tera!y of !rimary Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )20 Canadian Vascular Surgery Minimum o 2mage from .asilic vein .ilaterally" ten attem!t to stent wit Kianturco Y stent o 2f fails" consider central .y!ass vs 2$,femoral e/tra,anatomic wit KSV 144.%"y .ypasses for *enous repair are prone to failure? o Aow flow due to collateral circulation distal venous o.struction incom!etent valves "emed$- ?/b$5ass, AGD, 5e"ioo5e"a(i&e in(e"mi((en( %om5"ession o easily com!ressi.le grafts due to low !ressure in te circulatin de!endence on intraa.odminalLtoracic !ressure location .eind inguinal ligLliver "emed$- e7(e"na+ su55o"(, +a"ge diame(e" g"a'( o increased trom.ogenicity most !t ave lac: of !n C" S" A5 222 syntetic grafts more trom.ogenic "emed$- use au(o+ogous g"a'( use an(i%oagu+a(ion su"&ei++an%e 145.$ist $ perforators: o Connect KSV and dee! system o Normally" direct flow form su!erficial to dee! B/ce!t in foot H no valves tere Allows for measurement of AV' in su!erficial dorsal vein o Coc:ett 2" 22" 222 go from !osterior arc vein 0NO5 KSV1 to !ost ti.ial vein o a:a vein of Aeonardo F cm !osterior to medial edge of ti.ia along Ainton9s lineC o G" )2" )8 cm from floor" coc:ett ) at med malleolus o can9t get tis on wit SB'S o 'arati.ial !erforators 'ro/imal location 2 cm medial to te medial edge of ti.ia" go from KSV to !osterior ti. and !o! vein o 5igC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )2) Canadian Vascular Surgery Minimum ?unterian 0? for ig1 H in te mid ig tig #odd9s 0# for distal tig1 3oyd9s 03 for .elow1 H .elow :nee o Vein of Kiacommi H connects KSV and ASV o )0O of veins are com!letely du!licated o 2*O , !artially du!licated o No valves in C6V or iliac veins o 5o study !erforators" use descending !le.ogra!y Aow false !ositive ?ig false negative #u!le/ is .etter 146.Indications for perforator ligation: ave to ave CBA' class F and a.oveM& 6ailure of conservative t/ of severe stasis sym!toms Recurrent cellulitisLrecurrent #V5 during conservative treatment Relative H non,com!liance Contraindications to !erforator ligationC Cronic 'A# 2nfected ulcer Mor.id o.esity Non,am.ulatory and ig ris: !t RelativeC CR6" #M" Reumatoid artritis ResultsC )& #ifficult to distinguis .etween contri.ution of KSV ALS and !erforator surgery 2& ulcer ealing at )0 y H G0O E& recurrence 20O 0F0O in !ost trom.otic lim.s1 F& im!roved emodynamics 0Am.ulatory Venous 'ressure1 in some .ut not all studies *& !ossi.le tat sclerotera!y may .e .etter tan SB'S or surgeryM SurgeryC )& Su.facial Bndosco!ic 'erforator Aigation 0SB'1 2& O!en H modified 0for coc:et 21 E& O!en for te rest of tem H modified Ainton 0not done muc1 ResultsC SB'S O!en Ulcer ?ealing %FO 88O Ulcer recurrence ))O 22O -ournd com!lications *O 2FO Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )22 Canadian Vascular Surgery Minimum DIALYSIS ACCESS 147.Principles of A-1 creation: #OS2 wants at least *0O AV6 as autologous access& o 2f sort term dialysis needed R E wee:s H tem! line 0>uinton1 o Cec: K6R if RE0 mlLmin o Create access if antici!ate dialysis witin a year o Autologous if !ossi.le o Non,dominant lim. o #istal !ortion of u!!er lim. first o Venous imaging ifC Bdema in arm Collateral veins on cest on e/am 'revious linesL!acema:ers 0several1 'revious armLnec: surgery o Su.cutaneous !lacement o Order of !lacement in u!!er e/tremityC Radioce!alic 3asilic trans!osition in forearm .racioce!alic .asilic vein trans!osition a.ove el.ow loo! forearm AV '56B u!!er arm '56B o order in ABC try to use all arms first S6ALSV loo! '56B loo! -at is normal AV6 flowC total AV6 flows a.ove G00 mlLmin are enoug for dialysis& o ideally" aim for a flow of c)000 mlLmin& o minimum flow re>uired is E*0 ccLmin noted on G occasionsLmont 2f an AV6 flow falls .y 2*O or more in any given F monts" o AV6 e/am wit ultrasound or a fistulogram& 2000 mlLmin is too ig& US Sign of mature vein o F mm" Q*00 ccLmin H %*O maturation certainty o RF mm" R*00ccLmin H EEO maturation certainty Vein ma!!ingC Vein , Need 2&* mm .elow el.ow" E mm a.ove Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )2E Canadian Vascular Surgery Minimum Artery H at least 2 mm diameter Use tourni>uet for vein ma!!ing 2f vein Q * mm dee!" may need to su!erficiali;e it at te later date ?ig radial a& ta:e off may lead to steal in radioce!alic AV6 148.Access options in Central -ein Occlusion: Recanali;e vein endovascularly go to lower e/tremity" o Su!erficial femoral vein trans!osition o may use KSV if sure no need for lower e/tremity revascularistion in te imminent future& KVS vein 0does NO5 dilate muc even if trans!osed to arm1 reconstruction 04ug turn down" .y!ass1 2VC canulation o !ercutaneous tunneled cateter o ?eRO device tt!CLLwww&veitsym!osium&orgL!dfLveiL20%0&!df -eird and -onderfulC A/,fem,vein !tfe .y!ass as venoud outlflow A/illary,a/illary artery loo! 3unger" CM $VS 200*" F2021,2%0,2%* 149.Co!plications of A-1 creation: o 6ailure to mature o Stenosis 0!articularly at te venous end1 Aeads to trom.osis Surgery and !ercutaneous trom.olysis e>ually effective o Aneurismal dilatation o 3leeding tat can lead toM 'seudoaneurysm o Seroma tat can lead to M 2nfection o Steal tat can lead toC ?eart failure Swelling and Venous y!ertension Neuro!aty H monomelic neuro!aty 150. &reat!ent of A-1 steal: Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )2F Canadian Vascular Surgery Minimum Some coolness" stiffness and swelling are common after normal AV6 creation& So may want to wait awile to see if s/s settle& ReminderC steal a!!ens wit reduced inflow AN# increased outflow resistance in te arm com!ared to AV6 o #istali;ation of arterial inflow H for .racioce! AV6" move inflow distally to radial a& in a way" tis is li:e controlled .anding or creating a smaller inflow o 'ro/imali;ation of arterial access H for .racioce! AV6" move inflow to te a/illary artery& 5is moves !ressure sin: area !ro/imally and 5is im!roves inflow and decreases outflow resistantce to te arm com!ared to AV6& o #R2AC 'ro/imila;ation of inflow and increased resistnace to reversed flow ligate distal to AV6 .y!ass from 2,E cm a.ove AV6 to te !oint .eyond ligation& o #istal radial a& ligation if rad,ce! AV6C in a way" a form of #R2A must ave continuous !almar arc o Aigate fistula o 3anding fistula tt!CLLwww&fistulafirst&orgL!dfsLSurgicaldSalvage&!df LYMPHEDEMA 151.$y!p" p"ysiology: Aym! is !ro!elled .y intrinsic contraction of lym! vessels wit directing valves& B/ternal !ressure as little effect on trans!ort& -it dilation" wen cronic" a.ility to contract is lost& 5is results in settlement of !rotein ric fluid in te tissues& 152.Classify ly!p"ede!a: #ifferential diagnosis firstC AcuteC o Cellulites o #V5 o 5rauma o 6racture o 5orn ligamentLmuscle o Ru!tured 3a:er9s cyst o Acute lim. iscemia Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )2* Canadian Vascular Surgery Minimum Cronic o AV malformation o Aym!edema o CV2 o Systemic disease C?6 Aow !rotein Aiver failure Ne!ritic syndrome Refle/ sym!atetic dystro!y 0acute stage1 o fat E(io+ogi% %+assi'i%a(ion- o 'rimaryC Congenital R ) yoa Non,familial 6amilal 0Milroy1 H RoyL:ing .y .irt 'raeco/ ),E* yoa Non,familial 6amilial 0Meig1 H got my first Mig .efore E* 5arda Q E* yoa 5a,#AX 2 am old nowM o SecondaryC 6ilariasis Aym! nodeLvessel in4uryC surgery infection tumor rads trauma Ana(omi% %+assi'i%a(ion- #istal y!o!lastic 80O 'ro/imal y!o!lastic )0O ?y!er!lastic )0O Kender distri.ution 6emales Any gender Any gender Aaterality 3ilateral unilateral 3ilateral onset At !u.erty Any age Congenital 6am / 'ositive No 'ositive !rogression 3enign" slow course 6ast !rogression 'rogressive Res!onse to 5J -ell to conservative t/ 'oor to conservative t/ VV Res!onds to conservative t/ VVV VV !ro/imal y!er!lastic H May .e candidates for microvascular reconstruction Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )2G Canadian Vascular Surgery Minimum VVV y!er!lastic mesenteric lym!atics is incom!etent H reflu/ of cyle and !n losing entero!aty& Cylous drainage via vagina" scrotum" lower e/tremities& o May .e treated wit retro!eritoneal e/cision of incom!etent lym!atics& 153.$ong ter! co!plications of $y!p"ede!a: o AocalC infection 6i.rosis Neo!lasia 0lym!agiosarocoma" Stewart,5rives1 o SystemicC Malnutrition 2mmunodeficiency 154.&reat!ent of ly!p"ede!a: 9ndi%a(ions- 2m!rovement of lim. functionC MOS5 B66BC52VB indication o severe im!airment of mo.ility o Reduction of !ain Cosmetic im!rovement Reduction of com!lications o cellulitis" lym!angitis" lym!angiosarcoma T"ea(men(- o Conservative 5wo !ases H active decongentstion ten maintenance elevationLcom!ressionLmanual decongestion e/cerise !reventionLtreatment of cellulitis o !enicillin *00 mg 52# at first sign of infection .en;o!yrones o may .e effective in rea.sor.tion and mo.ili;ation of tissue !ns com!ressive garment is used for maintaining lim. si;e o surgeryC R )0 O of all !ts need tis e/cisional o!erations RARB o carles o Ainton , staged su.cutaneous e/cision .eneat fla!s microsurgical lym!atic reconstrationC V&RARB o lym!ovenous anastomosis o lym!atic grafting Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )2+ Canadian Vascular Surgery Minimum o free lym!atic fla! li!osuction UPPER LIMB 155.7enearl causes of upper li!. isc"e!ia: 2n general" u!!er lim. iscemia is due to s!asm" o.struction" or em.oli& -en !erforming an angio" always use vasodilators to assess distal s!asm H more ommonly seen in u!!er tan in lower lim.s& 2f see and wea:ness !ost .racial !uncuture H alsway e/!lore median nerve H small ematoma in te seat will cause !ermament damage&
o s!asm , ergotamine" 2V drug a.use" raynaude disease o o.structionC large vessel H Aterosclerotic ulcer H more !ro/imal su.lcavian 5OS H more distal su.clavian Arteritis o 5a:" KSA Radiation 6M#" #2SSBC52ON small H C5# o Scl" RA" SAB" S4o meta.olic o #M" CR6 myelo o trom.ocyto!enia" 'CV" Cold cryglo." y!ercoag" leu:emia trauma o vi.ration" cold in4ury" AV6 oter o 3urger" intraarterial in4ection" cytoto/ic drugs , cemo o Bm.oliC aneu , ventricular" inno" su.cl" a/il" .rac" ulnar !la>ue , arc" inno"su.clavi eart , A6" !ost M2" valve Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )28 Canadian Vascular Surgery Minimum 156.Sy!pto!s 3 signs of &OS: o 'ain < !arestesia" o -orse wit arm elevation o Occi!ital eadace o -ea:nessLmuscle atro!y 0uncommon1 o Aocal tenderness in scalene triangle o Blevation Arm 5est 0BAS51 H wit arm e/ernally rotatedLa.ducted" elevated can9t re!etitively o!enLclose fist for Q E0,G0 sec o Adson testC disa!!earance of radial !ulse wen ead rotated te oter way" .reat in o 'ositive !rovocative tests seen in normal lim.s as well& 157.Approac" to pt wit" &OS 5OSC Neuro H %*O Vein H FO Artery H )O OverviewC Review occu!ation" neurological" arterial" venous" Raynaud sym!toms& Assess location" laterality" degree of disa.ility& Review !m/ of com!ressive syndrome" nec:Lsoulder trauma" vi.rationalLoccu!ational in4ury" C5#" y!ercoag state" A6& S!ecific ?istoryC occu!ation" !rovocative maneuvers" and dominance num.nessLwea:ness 0neurogenic1 ulcersLand fatigueLclaudicationLnail s!linter emorrages 0arterial1 swellingLcatetersLrecent strenuous activity 0venous1 vasomotor sym!toms 0Raynoudes1 .ilaterality duration" wat was tried for relief" course of s/s over time" disa.ility , at wor: and life style limiting !rev / of o A6Lanticoagulation o #V5L?CS o C5#Larteritis Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )2% Canadian Vascular Surgery Minimum o Central lines o 5raumaC Nec: Rotator cuff tear ?and Vi.ration 6rost .ite o ### in nec: o Bntra!ment Ulnar median medsC OC' if female fam ?/C y!ercoag state ROSC functional status" degree of disa.ility&
B/amC .lood !ressure .ot arms" !ulse >uality !ulse distri.utionL.ruits !rovocative testing H o Adson , radial goes wen ead turned te oter way" .reat in& o BAS5 , e/ternal rotation" a.duction , can]t sustain fist clincing for more tan E0 sec& ?ig negative !redictive value test& wasting" wea:ness" sensation" refle/es" 5innel" 'alen test& Cec: for Rotator cuff tearsLwea:ness" .ici!ital tendonitis s!linter emorragesLulcersLAllen test& te rest of e/am , i&e& oter e/tremity" ?S" a.do etc& wor: u!C no test alone is indicative or fully diagnostic go .y !resentation / and !ysical CJR to cec: for ) st ri. o See in )O of !o!ulation" more in women" %*O of arterial 5OS ave it& #u!!le/ to assess vein and artery C5A if sus!ect aneurysm MR2 H .ut may not sow mucM o -ill rule out cervical dis: disease" syrin/" s!inal cord !ro.lems Nerve conductions studies are li:ely to .e normal o 2f a.normal H see median motor and ulnar sensory !ro.lems Ruterford recommends test in4ection of lidocain in to ASM o 2f .etter" ten may .enefit from surgery discussion Surgery is .etter viewed as #2AKNOS52C rater tan tera!eutic Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )E0 Canadian Vascular Surgery Minimum 158.Co!plications of E st ri. resection: o -ound ematomaLinfection o 2n4ury to intercosto.racial n& .racial !le/us long toracic n& toracodorsal n& !renic n& H tem!orary !alsy seen in )0O of cases sym!atetic cain vein artery o !neumotora/ o lym! lea: o !ersistentLrecurrent 5OS 159.Indications for surgery of a su.cla*ian a@ aneurys!: o Sym!tomaticC ru!ture" trom.oem.olism" !ressureC !ain" .racial !le/us o Si;e Q 2 cm o Note tat E0,*0O !ts wit aterosclerotic 0most common ty!e1 aneurysm will ave aneurysms elsewere 160.-i.ration w"ite finger: o Raynaud9s !enomenon due to !rolonged use of vi.ratory tools o Num.ness" tingling ,Q ti!s .lancing !!t9d .y cold o -it time affected area !rogresses o Only )O !rogress to ulcerLgangrene o Mecanism un:nown& o Cold !rovocation testing diagnostic o AngioC digital a& occlusion findings o 5/C avoid cold" may try CC3 for advanced cases& o Sym!atectomy is RARBA= needed o 2f digital gangrene H consider !rostoglandin B2Lilo!rost iv 161.Hypot"enar Ha!!er Syndro!e: o AnatomyC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )E) Canadian Vascular Surgery Minimum Ulnar aretery over y!otenar imminence is vulnera.le 5erminal .rances or ulnar a& may .e involved 0dee! < su!erficial !almar1 Arise in te canal of Kuyon& 3oundariesC Medial H !isiformLoo: of amate #orsally H transverse car!al lig Ulnar a& is su!erficial 0s:in" 'almaris .revis1 2ntimal damage H occlusionLaneurysm ?istoC 6M# in media" intimal disru!tion Raynaud9s !enoemenon" digital iscemia 3ut always s!ares tum. due to radial artery su!!ly Rarely ulnar a& occlusion 5/C conservative" C#5 if witin 2 wee:s ResectLre!air ulnar a& aneurysms to !revent em.olism o 6or graft H arvest distal KSV 0si;e matc1 o Aigate only if !almar arc is !atent 162.Occupational acro)osteolysis: o 6irst seen in wor:ers e/!osed to !olyvinyl cloride o Resor!tion of te distal !alange tuft" similar to scleroderma o Raynaud9s !enomenon o Angio digital occlusion AN# y!ervascularity ad4acent to .ony resor!tion 163.At"letic in<uries: o #igital artery occlusion 5rauma in catcers Cleland ligamentC from !alan/ to sc tissues" on !almar surface over '2' o Bm.oli;ation Suadrilateral s!ace o teres minor su!" umerus lat" teres ma4or inf" long ead of trice!s med o 'osterior circumfle/ a&" a/illary nerve o artery !rone to aneurysm in !itcers" volley.all toracic outlet 0leading to su.clavian aneurysmLtrom.osis1 Lowe LIMB 164.Differential diagnosis of .ilateral lower li!. swelling: SystemicC MC o 'itting edema Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )E2 Canadian Vascular Surgery Minimum o C?6 H .etter in am after su!ine" .ut may get e/acer.ation of C?6 o CR6 H not .etter in am after su!ine #rug induced H Adalat H mild 2liofemoral trom.osis Aorto,caval fistula Aym!edema o 5oes H Q groin" s>uaring of toes o Unilateral most commonly o ?y!er:eratosis of s:in" fi.rosis at AAS5 stages CV2 H MOS5 COMMON CAUSB in NA o Stigmata of CV2 o Almost never involves feet o 5e only condition to cause scarring of !erimaleolar s:in 0li!odermatosclerosis1 6at legs 165.Approac" to distal peroneal a@ o medial o !osterior o lateral wit fi.ula resection e/!osureC !eroneal a& is continuation of ti.io!eroneal trun: MedialC o in te u!!er calf" 5'5 is e/!osed tusC s:in" sc fat" !reserve KSV" fascia" divide soleus muscle over angled dissector" divide anterior ti.ial vein .eware of dense venous !le/us o in te middle calfC muscles of te dee! com!artment from medial to lateral H o 6#A H fle/ dig longus" o 6?A H fle/ al longus" o '5 H !ost ti. remove soleus from te edge of ti.ia" reflect soleus and KC !osteriorlyC '5 artery is found .etween !osterior surface of te 6#A and soleus H leave '5 artery in te fasciaLareolar tissue attaced to soleus Iee! going dee!er 'eroneal a& is found on te !osterior surface of 6?A" close to te fi.ula& o #istallyC 6ind !eroneal .etween 6#A and 6?A& 'osterior a!!roacC o #irect" fewer wound com!lications" for sort .y!ass wit ASV Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )EE Canadian Vascular Surgery Minimum o Su!ine o 2ncision in distal tird over lateral edge of te calcaneal tendon o Retract C5 medially and 6?A laterally Aateral a!!roacC o )0,)* cm incision o 2# Common !eroneal n&" !rotect o Se!arate muscle of lateral com!artment from fi.ula o B/cise fi.ula" may do so su.!eriosteally" dril in !laces of resection for clean cut o 'eroneal a& is Sitting rigt tere in te fi.ular .ed& 166.1ate of a claudicant: , 2N KBNBRAA" 20O deteriorate" )0O CA2" 2O lose lim.s 0more if dia.etic1& , #ecrease in A32 R 0&* is .est !redictor of deterioration in 2C and mortality , At * yearsC CV MOR32#25= 0non,fatal M2 or stro:e1 20O CV MOR5AA25= )0,)*O& Ris= o' +imb +oss in 9F %an be s("a(i'ied- !& )G" Ruterford o 2t is too sim!listic to say for all 2C ris: of lim. loss is )O !er year As is suggested .y B'2#BM2OAOK2C data from 6ramingam o 9' %+ini%a++$ %on'i"med, "is= o' L9M< +oss is %+ose" (o MK 5e" $ea" E&+O if diagnosis is esta.lised clinically *&8O if diagnosis confirmed wit non,invasive studies 8&* O if A32 .etween 0&F,0&G ?ence term su.critical iscemia Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )EF Canadian Vascular Surgery Minimum 6rom 5ASC 22C 2ntermittent claudication No intermittent claudication * year survival 8*O %*O )0 year survival *0O 8*O A32 R0&* is an im!ortant !redictor of overall survival& F+audi%a(ion managemen( o5(ions- Krade it first H wit treadmill& Ma/imum -al:ing #istance is MORB !redictive tan 'ain 6ree -al:ing #istance& A32 is te .est !redictor of a..revitated survival& KoalC 2ncrease >uality of life increase 'ain 6ree -al:ing #istance" and Ma/imum -al:ing distance o cilasta;ole o wal:ing e/ercise delay !rogression to CA2 o modification of R6 5oroug discussion reC natural / of claudication& )& 3enign H 20O worse" )0O CA2" 2O lim. loss )& See a.ove H may .e as ig as 8O !er year&& 2& Overall felt NO5 to .e a lim. treatening issue 2& 'ro.lem is glo.alC need to address all vascular .eds )& i&e& !ain in te leg is Aife style issue Managemen( o' "is= 'a%(o"s- Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )E* Canadian Vascular Surgery Minimum interestingly enoug" tis will not affect claudication distanceM o success in slowing te !rogreesion of 'A# and im!roving 2C has not been proved .y statistically significant valid clinical trials& Ruterford '& G02 .ut it ,i++ add"ess (he g+oba+ 5"og"ession o' a(he"os%+eo"isM o as .een sown to reduce te ris: of CA# and !rogression to CA2 S!ecifically" wat needs to .e doneC Smo:ing cessation o Smo:ing im!roves 2C distance in some .ut not oter studies" ence no consensus o Cessation will im!rove !atency of .y!ass E foldM o ))O of smo:ers wit 2C will undergo am!utation" com!ared to 0O in non, smo:ers o E fold iger ris: of needing intervention if !t as F0 !ac: year of Smo:ing ?5N control ?A control o Reduces !rogression to CA2 #M if !resent o 5reatment of #M was NO5 sown to reduce am!utationsM Anti!latelet medications Wa+=ing (he"a5$- (he on+$ non/o5e"a(i&e ("ea(men( sho,n (o im5"o&e 9F8 Su!ervised .etter tan non,su!ervised )*0 m difference" Cocrane" 200G E0 minLE times a wee: for E monts" increase to G0 min a session increase s!eed from 2 miL to E miL initial goal )0 min !ain free wal:ing ten start !using im!rovements in wal:ing efficiency" endotelial function and meta.olic ada!tations in s:eletal muscle Cocrane meta,analysisC )*0O increase in M-# o #RUKSC o Cilosta;oleC decreased !latelet aggregation < 5K" increased SMC rela/ation < ?#A meta.olism A.out )F0 m 0F*0 f1 Ruterford1" 5a:s 22 H *0,+0 m&&& E0,)00O M-# Mc side effectC eadace" diarrea o 'ento/yfyllineC reologic drug Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )EG Canadian Vascular Surgery Minimum Some studies sow .enefit" oters don9t 'lace.o vs drugC 2FO vs F0O in '6-# E2O vs 20O in M-# Overall li:ely small im!rovementC *0m 0)G0 f1 o O!erative interventionC .y!ass vs '5A& RC5C wal:ing vs endovascular" 200% +G !ts BN#O vs +* !ts wal:ing tera!y ?os!ital .ased 'roven mild" moderate and severe Claudicants Measure 6unctional ca!acity" M-#" '6-#" A32 im!rovement over )2 monts 2m!rovement in wal:ingC 1 ,ee= A mon(hs 13 mon(hs Bndo )st 88O +*O G8O -al:ing )GO ++O G*O B>uivalent o.4ective and su.4ective im!rovement .etween two tera!iesM Bndovascular tera!y does no( %"ea(e ne, indi%a(ions for an intervention& 2t defines a !o!ulation wit an acce!ted indication tat allows acce!ta.le im!roved outcome wit lesser intervention& 2deal tecnical outcome of an o!en .y!assC o !atency" lim. salvage and survival o seen in a( +eas( N0K o' b$5asses 9dea+ 'un%(iona+ ou(%ome a'(e" an o5en b$5ass- o ?os!ital free life" reintervention" wound ealing" significant cange in AM3UAA5OR= !otential o seen in on+$ 1MK o' a++ b$5asses: CAN#2#A5BS 6OR BN#OVASCUAAR 2N6RA2NKU2NAA 5?BRA'=C o Bconomic claudicants e/austed conservative trial of R6M" wal:ing" and cilasta;ole and wo understand tatC intervention is done for Aife style issues" not lim. salvage com!ared to o!en intervention" '5A offers an uncertain .ut reasona.le dura.ility com!ared to o!en intervention" '5A carries SMAAABR cance of conversion to CA2 and lim. salvage situation Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )E+ Canadian Vascular Surgery Minimum o !atients wit CA2 wit non,!roi.itive tissue loss AN# limited !reo! am.ulatory ca!acity des!ite an e/cellent antici!ated 5BC?N2CAA outcomes of te o!en .y!ass in te end are !redicted to ave su.o!timal 6UNC52ONAA outcome .ased on teir fea.le ealt status" nursing ome situation" !oor !remor.id am.ulation& 2n tese su.selected cases" minimal intervention tat converts CA2 0rest !ain or ulcer1 to claudication status is wortwile& o S2A as a 5ecnical ad4unct to o!en a!!roac allowing for !erformance of y.rid cases wen !urely o!en a!!roac is eiter im!ossi.le or im!racticalC 5ASC 22" 3 ty!e S6A lesion sort conduit , S6AL!o! inflow source management C6BA o!en and S6A angio 2f claudicants re!resent )*O of te o!erated u!on !o!lution" ten i]d a;ard *O would to .e tas: A and 3" and ence candidate for endo first o!tion& As far as te CA2 it is ard to !redict te num.ers&&& E0OD 167.C$I criteria: o Severe R' re>uiring o!iate analgesics for QF wee:s and eiter Ulcer An:le !ressure R F0 mm ?g 5oe !ressure RE0 mm ?g Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )E8 Canadian Vascular Surgery Minimum 168.(atural "x of pts wit" C$I: CA2 at diagnosisC o *0O receive revascularisation o 2*O are given conservative t/ o 2*O receive !rimary am!utations At ) yearC o 2*O CA2 resolved o 20O ongoing CA2 o E0O are AA2VB .ut am!utated o 2*O dead Note" tat !ros!ect of lim. loss is not universal& -it conservative management" *0O will :ee! teir lim. and F0O of ulcers will eal& 169.&ASC classification for iliac and S1A lesions: o 9+ia%- need to :now only A and 3 H as tese are te for endo" te rest is o!enM A C2A stenosisC uni or .ilateral B2A stenosis RE cmC uni or .ilateral 3 R E cm aortic stenosis Unilateral C2A occlusion Unilateral B2A occlusion o Not involving 22A or C6A C Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )E% Canadian Vascular Surgery Minimum .Ll C2A occlusion .Ll B2A stenosis not e/tending into C6A E,)0 cm uni B2A stenosis e/tending into C6A # 2nfrarenal occlusion Aortic Aneurysm Uni stenosis of .ot C2ALB2A .Ll occlusion of B2A o ;DA A Single stenosis R)0 cm Single occlusion R* cm 3 Multi!le stenosisLocclusion R *cm eac R * cm calcified Single stenosis R )* cm" not involving !o! ;ing+e o' mu+(i5+e +esions in (he absen%e o' %on(inuous (ibia+ &esse+ in&o+&emen( o To im5"o&e in'+o, 'o" dis(a+ b$5ass C Multi!le stenosisLocclusion Q)* cm Recurrent stenosisLocclusion after 2 endo treatments # Bntire S6A occluded 'o! or trifurcation occlusion 170.,ASI$ study: Randomi;ed !ros!ective trial 2+ UI os!itals F*0 !ts wit CA2 were randomi;ed 3y!ass vs '5A as ) st treatment wit CA2 due to infra,inguinal disease Crossover of !atients was allowed after randomi;ation 5wo strategies 7.roadly similar8 wrt o am!utation free survival" o all,cause mortality o >uality of life in te S?OR5 term& o Surgery )LE more e/!ensive Ia!lan,Meier !lots for long termC o am!utation free survival and all cause mortality favour '5A ) st for te first 2 years" o .y!ass was .etter !ast 2 years& Overall" at te end of E years" o ;u"ge"$ 2 MLK am5u(a(ion '"ee su"&i&a+ Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )F0 Canadian Vascular Surgery Minimum o .TA 2 M3K am5u(a(ion '"ee su"&i&a+ o )&e"a++ +onge&i($ / M0K Hen%e, i' +i'e e75e%(an%$ is +ess (han 3 $ea"s, o''e" .TA8 9' +i'e e75e%(an%$ mo"e (han 3 $ea"s, o''e" su"ge"$ 8 171.-ein ad*antages o*er prost"etic: Com.ines many of te ideal >ualities of te graftM o 3iocom!ati.le Resists trom.osis B/cellent ingrowt Aess infecta.le ?eals if infected dura.le o similar to native .io!ysical matcC im!ermia.le 3etter si;e matc Com!liance similar Krows wit arterial system o Aogistical Cea! Availa.le Basy to andle As a "esu+(, &ein has be((e" 5a(en%$ 172.Options for .ypass graft !aterial in descending order of preference: o KSV o ASV o Arm vein o Com!osite graft 0wit ad4uncts H venous cuffL!atc1 #o not do straigt !tfe,vein anastomosis Rater" !tfe goes to .lind arterial segmentLdistal S6A Vein ta:es of distal to te !tfe" NO5 off te ood of te !rostetic .y!ass o SV6 o 'rostetic 0e!arin .oundQ'56B" #acron1 o Cadaver KSV Cryo!reserved ) year !atency 28,80O 2 year !atency )%,F0O Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )F) Canadian Vascular Surgery Minimum Barly failure )+O Aate aneurysm *,E0O Aim. salvage G0,)00O '&+20,2) o Allogenic veinLartery NoteC in tig and calf" G*O of KSV is single" E*O , dou.le system most common location of a..erantly !laced KSV is AN5BRO,AA5BRAA to usual location& Cryo!reserved veins are NO5 .etter tan a./ .onded graft in infected field wrt !atency\ According to Ruterford9s Com!anion" ?UV is 3B55BR tan multis!liced vein for distal .y!ass& 2t also as same rate of infection as autologous vein& ?UV as outer su!!orting mes and needs s!ecial andling& Antiocoagulation" cuff !atc will im!rove !atency of 3I !rostetic .y!ass 173.Synt"etic grafts + c"aracteristics: o woven long 0war!1 and circumferencial 0weft1 tread !attern low !orosity strong stiff doesn9t dilate !oor andling" fray at edges recommended for ru!tures and toracic re!lacement o :nitted !redominantly long 0war! H long way from ome" Star5re:1 lea:s H need !reclotting fle/i.le" comforta.le dilates wit time o veloure micro loo!s on te outside designed to im!rove incor!oration into tissues and !rotein adesion H to reduce !orocity& o Irim!ing adds fle/i.ility and elasticity may interfere wit laminar flow smaller diameter may cause increase trom.ogenicity o .iologic coating Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )F2 Canadian Vascular Surgery Minimum wit al.umine to im!rove !orocity issue more e/!ensiveM saves time H no need to !reclot Bndotelial seedingC still e/!erimental do not decrease anastomotic y!er!lasia owever" sow .etter !atency at E years only F0O of attaced cells remain on graft at 2F 174.Ad*erse effects of -ein "ar*est: o #issection tecni>ue H trauma to vessel wall" tying .rances too close o 6orceful dilation H :ee! under 200 mm ?g" oterwise will sloug endoteliumN 2t leads to in4ured vessel wall tat will aveC o Aeu:ocyte infiltration o intimal tic:ing via intimal y!er!lasia neointima" SMC ingrowt in intima" intimal matri/ de!osition o su.intimal fi.rosis Bndotelial disru!tion leads to te following effectsC loss of fi.irinolityc a.ility increased A#A u!ta:e loss of NOL!rostocyclin secretion o 5em!erature H conflicting E+ degrees C vs 2,F" less !rostocyclin < NO syntesis su!!ression wit room storageM Ruterfords com!anion recommends COA# o SolutionC -arm wole .lood .etter tan cold crystalloid& 'a!averin !revents vasos!asm ?enceC gentle dissection" under 200 mm" e!arini;ed cold saline wit !a!averine 175.xpected patency of *ascular grafts 3 procedures: 9+ia% angio5+as($- 2222 lim.s +GO claudicannt ) year H 8*O * year H +0O ;DA 2 5oo+ed "esu+(s- TA;F 99 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )FE Canadian Vascular Surgery Minimum ) year E year * year '5AC stenosis +*O G0O **O '5A P stentC stenosis +*O G*O , '5AC occlusion G*O *0O F0O '5A P stentC occlusion +0O G*O , i&e& stent offered a.out *O im!rovement M $ea" 'em 5o5- Claudicant CA2 Vein 80O G*O AI '56B +*O *0O 3I '56B G*O G*O 2 am !u;;led as to wy 5ASC 22 offers no e/!lanation for !atency for 3I '56B .eing e>ual for claudicants and CA2M A@ .TDE &s &ein- se&e"a+ RTF ana+$sis, a( M $ea"s 2 TA;F 99 "esu+(s Vein +*O '56B *0O 0o!timistic1 5ere is NO dou.t tat A3SOAU5B !atency of AI vein graft is su!erior to '56BM Classic Veit RC5 studyC F year results vein '56B Stat significance 3elow :nee G8O F+O 0&02* A.ove :nee G)O E8O 083M 6J;# Comment H low num.ers" .ut trend was toward vein su!eriorty in a.ove :neeM VA .oston study" 2000 AI location" no #M" no women * year results 2n tis study" ?US was used as well and did .etter tan '56BM (J Vasc Surg 2000;32:268-77.) claudication CA2 Vein 80O G8O '56B EEO E+O Ilinert" 200F Metaanalysis At F years" tere is 20O difference .etween vein and '56B Selected F >uality RC5 G%O vs F%O in favor of vein& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )FF Canadian Vascular Surgery Minimum NO5BC 200% Cocrane analysis on AI vs 3I veinL'56B is USBABSS H no recommendation given" studies are !oor" etc& #one .y te RN" not M#& ?eavy criticism of tis study at 200% ?arvard Review course& Aim. .ased * year )0 year Aorto.ifemoralC claudication %0O 8*O Aorto .ifemoralC critical lim. iscemia %0O 80O A/illo,uni *0O A/illo,.i,fem +0O 6em,fem +*O )%%% metaanalysisC 2m!rovement in !atency of !rostetic grafts 0.ut not autogenous1 wit anti!latelet t/& * year !atency according to 5ASC 22C %0O grou!C o Aorto,.i,fem +0O grou!C o 6em,fem o 6em,!o! 3I vein o 2liac,'5A o A/,.ifem *0,**O grou!C o A/,unifem o S6A angio!lasty for stenosis Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )F* Canadian Vascular Surgery Minimum F0O grou!C o S6A angio!lasty for occlusion o 6em,distal .y!ass E0O grou!C o 6em,!o!,3I !rostet Oter info re !atencyC O'BN S6A 3='ASS RBSUA5S according to 5ASC 22 Claudicant CA2 Vein 80O G*O AI '56B +*O *0O 3I '56B G*O G*O Results of S6A endovascular !atency according to 5ASC 22" cumulative ) year E year * year '5AC stenosis +*O G0O **O '5A P stentC stenosis +*O G*O , '5AC occlusion G*O *0O F0O '5A P stentC occlusion +0O G*O ,
176.Co!plications after infrainguinal re*asculari>ation:
Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )FG Canadian Vascular Surgery Minimum BSR# is s!ecial caseC for infrainguinal .y!assM& BSR# wit BSR# CA2 wit NO BSR# 'erio!arative mortality *,)0O 2,EO Survival *0O at E years *0O at * years -ound < incision ealing 'oor 3etter 5ose wo !ersue aggressive indiscriminate revasculari;ation of tese !ts are not !racticing evidenced .ased medicine& 0Ruterford1 AS2#BC Cryo!reserved vein for infrainguinal .y!assC ) year !atency H 28,80O 2 year !atency H )%,F2O Barly failure H )+O Aate aneurysm H *,E0O Aim. salvage H G0,)00O So !atency rates are NO5 sterling" so ma:e your own conclusions& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )F+ Canadian Vascular Surgery Minimum 177.7raft sur*eilance: )*,20O of graft fail witin * years o )0 O , see failure in first E0 daysC 'oor >uality vein 'oor anastomosis 'oor outflowLinflow 9n u5 (o A0K o' ea+$ 'ai+u"e a"e due (o g"a'( +esions o 'oor vein vs valve vs twist vs anastomotic narrowing Te%hni%a+ e""o"s "es5onsib+e 'o" 4/3MK g"a'( 'ai+u"es A( e75+o"a(ion, M0K o' g"a'(s ha&e no a55a"en( 5"ob+ems8 6ailure in first 2 yearsC o Mostly due to intimal y!er!lasia 25 is critical to detect failing graftC Most veins don9t stay o!en after mecanical trom.ectomy or trom.olysis o 'atency after trom.olysis is 20O at ) year o At ) year" *0O are am!utated" 2*O ave rest !ain" )*O deadM 3ut lim. salvage may .e .etter o Surgery is a .eter o!tion ifC 5a:en to OR immediately Mecanical !ro.lem is detected 0twist" valve cus!1 5raditional ways to detect failing graft lac: sensitivity o Recurrent sym!toms o AossLreduction of !ules o A32 cange of Q 0&2 ''V )2,EFO" i&e& AO- 8O of lesions develo! in first year o Aesions develo!ing in first E monts are more treatening tan late ones 5ere is 2,FOLyear late graft stenosis 2N A##252ON to )0O life time ris: of !rogression of aterosclerosis& 6irst surveylance du!le/ studyC at discarge or ) mont" o ten .iannually for 2 years" o ten annually for life Cec: KV6" 'SV in te lesion& Krade ris: level& Revise grafts at ig ris: Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )F8 Canadian Vascular Surgery Minimum R9;@ LEGEL H9IH/GEL)F9TT FR9TER9A L)W/GEL)F9TT FR9TER9A A<9 REDHFT9)J ?igest 'SV Q E00 cmLsec or Vr Q E&* Or B#V Q )00 cmLsec and K6V R F* cmLsec or Q0&)* ?ig 'SV Q E00 cmLsec or Vr Q E&* and K6V Q F* cmLsec and R0&)* 2ntermediate 'SV )80,E00 cmLsec or Vr Q 2&0 and K6V Q F* cmLsec and R0&)* Aow 'SV R )80 cmLsec and K6V Q F* cmLsec and Q0&)* A32" an:le,.racial inde/N 'SV" !ea: systolic velocityN Vr" ratio of te 'SV witin te lesion to te 'SV in a !ro/imal normal segment of te graftN K6V" graft flow velocityN B#V" end,diastolic velocity& Krafts at ris:C tese need angio and li:ely revisionM& o low,flow velocities in te graft !ea: systolic velocity R F* cmLsec trougout te graft o 'SV Q E00" B#V Q )00 5ese need to undergo angiogra!yC o d"o5 in A<9 e7%eeding 081M in (he absen%e o' de(e%(ab+e g"a'( +esions need arteriogra!y to searc for inflow" outflow" or missed graft lesions Krafts wit low and intermediate ris: H followC > E monts o *0O of tese will !rogress& Vein graft surveillance im!roves long,term vein graft !atency .y a!!ro/imately )*O RC5 .y Aundel" multi!le o.servational studies Cost effective 0multi!le studies1 2n general" o!en re!air wit !atc or inter!osition gives .est results& 178.Iliac P&A + risks of procedure: o #issection o Ru!ture o #istal em.olisation o 5rom.osis o Restenosis o 6alse aneurysm o 2nfection 0if use stent1 179.Pri!ary and secondary patency: Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )F% Canadian Vascular Surgery Minimum 'rimary H o O of grafts tat remain !atent" witout failure" over a given time o 2ncludes grafts tat were rescued 'R2OR to occlusion 0assisted ) o !atency1 Secondary , o O of grafts tat remain !atent A65BR it was restored following failure o #oes NO5 include !rocedures wen new graft is inserted Li'e (ab+e me(hod- Can .e used for data sets MORB tan E0 !ts only 2nitially used to measure survival of cancer !ts and effect of tera!eutic intervention Bvents 0graft failures1 are grou!ed into intervals Survival is ten calculated for eac interval Ma4or assum!tionC o all witdrawals occur in te middle of te interval o failure rate is sta.le over te interval duration 6ailure rateU num.er of failuresL0num.er at ris: H e num.er of witdrawals1 Curves are straigt lines" not ste!s 2nformation needed for life ta.leC o 2nterval !eriod o Num.er of !ts at ris: for eac interval o Num.er of !ts witdrawn !er interval o Num.er of failures !er interval Cumulative !atency o Cumulative !atency for ) st interval U Success rate U ) H failure rate o Cumulative !atency of te 2 nd interval U success rate for ) st interval J success rate for 2 nd interval @a5+an/Meie" Me(hod- 'roduct,limit metod #ate is not grou!ed in intervals o Or interval are very small and contain only one o.servation !oint Bvent occur at individual failure !oints No corrections are needed for witdrawals Kra!ically re!resented as stair Hcases o 3etween events" noting is :nown a.out te failure rate H it is assumed to .e 0M A!!ro!ritate for AN= data si;e Com!arison .etween !atencyC use log,ran: test of significance Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )*0 Canadian Vascular Surgery Minimum 180.&ests for e*aluation of t"e donor iliac artery prior to fe!)fe!: o 'al!ation of fem !ulse o 5ig,.racial inde/ o 5ig !letysmogra!y H .ris: u!stro:e and good e/cursion o #u!le/ of iliac H 5ri!asic No 'SV elevation S!ectral window !reservation o 32'AANAR angiogra!y H evidence of anatomic stenosis 2f >uestiona.le lesion H wal:ing A32 or angio wit vasodilation o #irect 6em artery !ressure measurement Normal H less tan * mm ?g gradient wit CA side Normal H less tan )*O dro! wit vasodilation 181.Popliteal aneurys!: o Male" elderly !ts H G,+ t decade o *0,+0O are .ilateral o E0O ave AAA o E0O ave fem Aneu o F0O involve ti.L!er trun: o ClassificationC 6usiform vs saccular 'ro/" mid" distal o Asym!tomatic in E+O o 2f sym!tomaticC 2scemic 0!rogressive em.oli;ation" trom.osis1 H **O Aocal effect GO 'o! mass 'ain Venous com!ressionLedemaL!le.itis Ru!ture )&FO o -en to fi/C All sym!tomatic Asym!tomatic Q 2 cm o ORC Bndo vs o!en Single small RC5 sowed e>uivalence of results Antonello" 200+ u!date )5en 3L 5(s Endo 31 5(s 5 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )*) Canadian Vascular Surgery Minimum )2 monts )f )00O 8G&+O NS 2f )00O )00O NS +2 monts )f +)&FO 88&)O NS 2f 88&)*O 8*&%O NS O!enC Medial vs !osterior a!!roac ?uang" 200+" F year o 'rimary !atency 8*O 0vein1" *0O 0!tfe1 o Secondary !atency %FO 0vein1 vs GEO 0!tfe1 Consider intrao!erative trom.olysisLisolated lim. !erfusion 2f elective" R)O mortality and lim. loss 2f emergent *O mortality and u! to 20O lim. loss 26 see .ot AAA and !o!liteal H fi/ !o!liteal aneurysm first H oterwise ris: trom.osis in !erio! !eriod& 0Ruterford1 182.Approac"es to pop aneurys! repair: ad*antages and disad*antages MedialC A#VAN5AKBSC easy KSV arvest" su!ineLnot !rone !osition H easier for KA" no ris: for retinal iscemia familiar a!!roac" can get far remote and distal access to S6ALtrifurcation avoid ti.L!eroneal nerves #2SA#VAN5AKBSC Sa!enous n& in4ury #ifficult to get into aneurysm Aong scar 'osteriorC A#VAN5AKBS Basy access to aneurysm H ligate all te feeding .rances Basy way to decom!ress aneurysm Can do inter!osition re!air Basy access to ASV Can go furter distally H 4ust s!lit te gastrocnemius Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )*2 Canadian Vascular Surgery Minimum Smaller cosmetic incision #2SA#VAN5AKBSN Unfamiliar territory 'o! vein and ti.L!er nerves in te way H in4ury !otential Can9t go far !ro/imal Can9t easily get KSV 'rone !osition H more difficult to KA 0ris: to eyes and airway loss1 -ound ealing !ro.lem 183.7oals of perip"eral aneurys! treat!ent: o Bliminate source of ateroem.olismLtrom.osisLru!ture o Bliminate mass effect o Maintain distal !erfusion o 'revent recurrence 184.(er*es encountered in popliteal a@ exposure: o 5i.ial o Medial sural H off ti.ial o Common !eroneal o Aateral sural , off common !eroneal o Medial receives a .ranc off lateral .ranc" and from median 0lesser1 sa!eous nerve AsideC Sa!enous n& H medial calfLfoot Sural n& H lateral foot Su!erficial !eroneal H foot dorsum #ee! !eroneal H ) st we. 5i.ial H !lantar surface 185.Cystic ad*entitial disease: o Mucinous cystLgangion in te arterial wall o Mc location !o!liteal" Second most common site , B2A Also seen in C6A" radialLulnar" KSV at S6$ o Male more common tan female o 5eoriesC Origion form Kanglion H o Since lesions are seen near te 4oint re!etitive trauma Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )*E Canadian Vascular Surgery Minimum systemic disorder develo!mental H te most !lausi.le teory of all o inclusion of mesencymal mucin secreting cells in adventitia during a.errant em.ryonic develo!ment o NoteC a!art from develo!mental" tere is no su!!ort to te teories !resented ere o 5reatmentC cystotomy , cyst evacuation 0NO5 resection1 o!en , 3BS5 com!ared to !ercutaneous re!lacement if trom.usLfi.rosisLaneu 186. Angio findings in ad*entitial cystic disease o Smoot ta!ering stenosis concentric cyst H our glass a!!earance eccentric cyst H scimitar sign o arterial occlusion 0seen later1 o 'ro/imal artery free from aterosclerosis 187.Causes of popliteal a@ occlusion in order of fre2uency@ o 'ro/imal sourceC Bm.olus Aortic dissection o Aocal sourceC 5rom.osis of ateroscleoritic lesion Aneurysm 2n old H degenerative AAA 2n young H tin: infected aneurysm 02V drug use1 'o! entra!ment Cystic adventitial disease 5rauma 0:nee surgery" disarticulation1 6M# 3uerger9s 'seudo/antoma elasticum 'ersistent sciatic artery 188.&ypes of popliteal entrap!ent: o normally !o! a& goes .etween eads of gastroc 0?OK1& o 5y!e ) H !o!& a& lies a.normallyC medial to normally !laced medial ?OK NO5 te most fre>uent ty!e o 5y!e 2 H !o!& a& is com!ressed .y A.normally 0more laterally1 !laced ?OK Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )*F Canadian Vascular Surgery Minimum o 5y!e E H !o!& in normal !osition" com!ressed .y a.normal lateral sli! of muscleLtendon o 5y!e F , !o! a& is com!ressed as it runs dee! to !o!liteus muscle o 5y!e * H any ty!e 'AUS !o! vein PL, ti.ial n& involvement Vein is involved in )LE of cases o 5y!e G H functional H i&e& no a.normality is identified .ut !o! artery is com!ressed in certain !ositions -en e/amining" ma:e sureC Ascertain a.sence of aterosclerosis R6 and vasculitisC o ?5N" #M" ?A" smo:ing" 6? of !remature asc" omocysteinmeia B/amine contralateral e/tremity Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )** Canadian Vascular Surgery Minimum Bvaluate arterial" venous and neurologic status Cec: out !ulses during stress testC tensing of te gastroc o 'assive dorsifle/ion o Active !lantarfle/ion NoteC stress test is !ositive in )LE of normal individuals Angio findingsC o Medial deviation of !o! artery o Mid !o! segmental occlusion 0wit stress1 o 'ost,stenotic dilatation All !ts wit ty!e ),* sould .e fi/ed H !rogress to occlusionLaneurysm 6or ty!e G H indications is less clearM o may .e entra!!ed .y sligtly mal!ostioned soleusLmedial ?OK o may consider division of te muscle ead if no oter e/!lanations of s/s& Resect artery ifC fi.rosis" aneurysm" trom.us on intimal surface 189.Causes of early li!. ede!a after a fe!oro)ti.ial 7S- .ypass o At one year" )0,20O o #isru!tion of lym!atics 0most im!ortant1 Blevate" com!ression dressing o Surgical trauma H inflam res!onse" increased 26 accumulation o Venous interru!tion Not a contri.uting factor unless tere is o #V incom!etence o #V5 190.Causes of co!part!ent syndro!e: o #efinition of Com!artment syndromeC 'ressure increase in te constrained s!ace" Most commonly due to interstitial fluid swelling CausesC o Restricted com!artment volumeC Casts Constrictive dressing MAS5 Circumferencial escar o 2ncreased volume of com!artmentC S!ace occu!ying lesions o ?ematoma o A.scess o Synovial fluid 0ru!tured 3a:er9s cyst o 2nadvertent infusion of crystalloid Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )*G Canadian Vascular Surgery Minimum Swelling of soft tissue" !rimarily muscle o 2scemia,re!erfusion in4ury o Venous outflow o.struction o 5rauma o Ris: factors for CSC QG iscemia Com.ined vein and artery trauma 'articularly if accom!anied .y vein ligation 'o!liteal artery in4ury Massive soft tissue in4ury S/sC )& !ain out of !ro!ortion to te !ysical findings" getting worse 2& distal motorLsensory dysfunction according to com!artment a& wea:ness of dorsifle/ion and num.ness of ) st dorsal we. s!ace in AB .& wea:ness in wrist e/tension and num.ness in ) st we. s!ace in UB E& muscle !ain" worse wit !assive fle/ionLe/tension Arterial !erfusion !ressue H gradient .etween MA' and interstitial !ressure& 2ntervention is recommended wen com!artment !ressure is witin 20 mm ?g of te diastolic or E0 mm ?g of te MA' for Q F ours& A.solute num.ers are generally misleadingM 2ndirect test to RUAB OU5 CSC do #US of te veins in te affected com!artment H !reservation of normal res!iratory !asicity will rLo CSM !&)0G) o legs H flow augmented wit e/!iration and ini.ited wit ins!iration o arms H te o!!osite 5/C Barly recognitionC F com!artment fasciotomy in lower e/tremity U!!er e/tremity Curvilinear volar incision antecu.ital fossa,Q!alm" o!en u! Car!al tunnel Oter !laces H longitudinal over involved com!artement B&g& over dorsum of metacar!alLmetatarsal .ones AsideC %h"oni% %om5a"(men( s$nd"ome H re!eatative lower e/tremity anterior com!artment 0most common1 !ain wit minimal e/ertion& Normal circulation& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )*+ Canadian Vascular Surgery Minimum #s H tenderness over com!artment and loss res!iratory !asicity of veins in te com!artment& 5/C cosmetic incision and fasciotomy curative& 191.Calf co!part!ents: AnteriorC 5A" B?A" B#" 'eroneus tertius" dee! !erineal n& AateralC 'eroneus 3revisLAongus 'ost #ee!C 5'" 6?A" 6#" !o!liteal" ti.ial n& 'ost su!erC KC" Soleus" !lantaris 192.Acute li!. isc"e!ia classification: o Category )C via.le" no motorLsensory loss" arterial #o!!ler !resent may do angio o Category 2aC marginally treatened" mild sensory loss" no motor loss" no arterial #o!!ler signal" venous #o!!ler !resent may do angio" .ut consider surgery soon o Category 2.C immediately treatened" mild motorLsensory loss ave to go to OR" angio on ta.le if needed o Category EC irreversi.le" anestetic" !aralytic" no arterial AN# venous #o!!ler& 5oo late" am!utation Signs suggestive of irreversi.le lossC )& 6i/ed cyanosis 2& Mar.led mottling E& MyositisC doug consistency" calf !ain" muscle rigidity F& Anestetic sensory loss *& Com!lete !aralysis G& No s!ontaneous venous do!!ler 193.A!putation le*el and .ones: 3IA H ti.Lfi. Syme H distal ti.Lfi." 0&* cm !ro/ to an:le 4oint Aisfranc H forefoot disarticulation at tarsal,metatarsal 4oint Co!art H midtrasal disarticulation H at talo,navicular 4oint 194.Define different types of a!putations: 6ailed infrainguinal revasculari;ation will NO5 affect level of am!utation" nor will it increase !erio!erative am!utation mortality& ?owever" it may !rolong wound ealing and long term survival of te !t& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )*8 Canadian Vascular Surgery Minimum o 5oe H OM" neuro!aty confined to distalLmid !alan/" fismout incision" !reserve small .utton of !ro/ !alange over M5 ead" no !rostesis needed o Ray H locali;ed gangreneLinfection to M5' crease or involving ead" rac>uet incision" divide nec: at F* degree !lantar .evel" ortotic may im!rove .alanceLminimi;e s:in trauma o 5MA H total !lantar fla!" gangreneLiscemia of multi!le toes s!aring !lantar s:in may need to modify soe wit steel san: to allow normal 7toe8 !us off and !revent e/cess dorsifle/ion o 3IA H 2N#2CA52ONC KangreneLinfectionLunreconstructa.le R'Lnon, ealing ulceration and CAN95 do more distal am!utation& MC !osteriorly .ased myocutaneous fla! on KC and Soleus muscles& Need !rostesis& F0O energy increase" E0,+0O am.ulate again o Inee disarticulation H occasional use" o if good .lood su!!ly" .ut as contracture or can9t do 3IA& #ifficult !rostesis& 5y!es of fla!sC o Aong anterior" o e>ual ant < !ost" o e>ual med < lat fla!s& Condyles H must .e transected to allow !rostesis o AIA , in .ed ridden" KangreneLinfectionLunreconstructa.le R'Lnon,ealing ulceration and CAN95 do more distal am!utation fis mot" ant < !ost fla! te longer te saft" te .etter te am.ulation !otential u! to *0,+0O energy increase )0,E0O am.ulate o ?i! disarticulation 0rarely !erformed1 o AsideC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )*% Canadian Vascular Surgery Minimum 6inger am!utations are .etter dealt wit .y !lastic surgeon Re!lant may not .e as functional as am!utation One study" sowed %0O e/cellent functional outcome wit finger am!utation vs FFO wit re!lant ?aving said tis" do not rus to ray am!utation H it will decrease gri! strengt and a.ility to su!inate& 195.&ests to use to select le*el of a!putation: 2n general ratio of AIA vs 3IA is )to ) o ClinicalC QG0 mm an:le H o: for 3IA Accuaracy *0,%0O 2&e& could .e a coin tossX Q F0 mm toe H o: for 3IA o Angiogra!y 0!oor1 o S:in tem! Q %06 o Segmental and toe !ressure o 5ranscutaneous o/ygen saturation 0most accurate1 R E0 mm ?g" !ro.a.ly o: o 2ntradermal isoto!e .lood flow o OterC S:in fluorescence < Aaser #o!!ler S:in !erfusion !ressure 196.Co!plication of .elow knee a!putation: 5ASC 22 o SystemicC #eat Barly )0O for 3IA")*O for AIA o BSR#" se!sis" acute iscemia #OU3AB mortality Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )G0 Canadian Vascular Surgery Minimum o ?ence" !ysiologic 0dry ice1 and two stage am!utation At two years E0O M2 'BL#V5 F0O 'ulmonary )0O Renal insufficiency se!sis stro:e de!ression H seen in E*O o AocalC Barly o .leedingLematoma o !ain H !antom vs stum! +0O ave it !ost o! 2*O !ain severe Bventually settles o stum! non,ealing )*O o stum! infection H E0O o revision to AIA H )*O AateC o contralateral am!utation )*O o a.ove :nee am!utation )*O o MSI !ro.lemsC 6le/ion contracture .one s!urs and osteo!orosis aderent scar stum! edemaLcongestion e/cessive residual soft tissue callous and cyst o neuromas o failure to rea.ilitate only F0O wal: at 2 years ruteford is more o!timistic *0O ave SOMB a.ility to am.ulate at ) year 197.Co!pare arterial/ *enous and neuropat"ic ulcers@ o Arterial H dorsum footLdistal" no .leeding wit mani!ulation" irregular edgeL!oor granulation" no surrounding inflammation" atro!ic cangesLno !ulse" !ain worse at nigtL.etter wit de!endencyLworse wit elevation& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )G) Canadian Vascular Surgery Minimum o Venous H gaiter area" venous oo;e on mani!ulation" sallow round edgeLgood granulation" surrounding inflammation" li!odermatofi.rosisL!igment" mild !ain" relieved .y elevation o Neuro!atic H under callusesL!ressure !ointL)<* M'$" .ris: .leeding wit mani!ulation" !unced out" dee! sinus" surrounding inflammation" as neuro!aty" normal circulation" no !ain& SoC Consider location" res!onse to mani!ulation" .lood su!!ly" !ain res!onse to !osition" stigmata of associated disease 198.Pat"op"ysiologic !ec"anis!s in dia.etic foot: o Arterial iscemia in ti.Lfi. vessels 5ere is NO microcirculation !ro.lems contrary to initial animal e/!erimentations 'rofunda and crural vessesl are affected o Neuro!atyC loss of nociL!ro!rioce!tion leading to trauma Aum.ical muscle denervation 6oot arcitecture messed u!C o cavus < claw toe o fle/ture contracture Aoss of neuroinflammatory res!onseC res!onse to infection is .lunted Normally" 'ainLinfection causes release of neuro!e!tides 0su.stance '1 tat release istamine" increase !ermea.ility and attract cells to site of in4ury& Neuro!e!tides ARB released .ut tere is no umeral res!onseM o Sym!atetic dysregulationC AV sunting 0less !erfusion to te tissue" more to te s:in no sweat ,Q dry s:in o Klycosylation of .asement mem.rane and tissue !roteins ,Q Aimited 4oint mo.ility B/travasated al.umin cause tissue edema difficult to eal incisions noteC tere is NO effect on o/ygen or nutrient diffusion All leads to !ro!ensity to re!eat trauma" loss of !rotective refle/es and weigt .earing redistri.ution& #ecreased arterial circulation com!licates matters furter& 2f no !al!a.le !ulses H need angio& 2f diminised !ulses H i&e& less tan tri!asic H non,invasive study first to see if #SA is re>uired& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )G2 Canadian Vascular Surgery Minimum #irect >uote from RuterfordC UThe 5"esen%e o' neu"o5a(h$ gene"a++$ "eBui"es a "e&as%u+a"iza(ion unde" %ondi(ion o' 5e"'usion (ha( ,ou+d no( "eBui"e "e&as%u+a"iza(ion in (he absen%e o' neu"o5a(h$8 U Non,invasive tests of arterial inflow" including 5C O2 sat" can .e !oorly !redictive of ealing under tese circumstances& )s(eom$e+i(is &s Fha"%o( 'oo( - Carcot footC !rogressive degenerative osteo!orosis of foot .ones secondary to neuro!aty& Aeads to deformities" foot swelling and erytema& Carcot foot !resents wit swelling and erytema& 2F .ed rest witout anti.iotics sould settle Carcot foot" .ut not osteomyelitis& E&a+ua(ing 5( ,(h Dibe(i% u+%e"'oo(- #rainage s/s Usual 'V# >uestions Se!sis review R6 and R6 5/ On B/amC 'ulses H d! and !t gotta .e tri!asic 2# ulcersLsinus" dd arterialLvenousLneuro!atic 'ro.eLde.ride necrosis Aoo: for e/!osed .one #o !lain /,ray loo:ing for gasM )&e"a++ 5"in%i5+es in ("ea(ing diabe(i% 'oo(- #e.rideLdrain o.vious infection Control systemic se!sisLy!erglycemia Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )GE Canadian Vascular Surgery Minimum Assess for Asc occlusive disease" as well as neuro!aty #efine status of 6OO5 arteries Restore ma/imum !erfusion !ossi.le Aoo: for" drain" de.ride residual infectionLnecrosis Manage o!en wounds wit dressing CAROTIDS 199.,ranc"es of xternal Carotid artery: o Anterior Su!erior tyroid Aingual 5ransverse 6acial 6acial o 'osterior Occi!ital auricular o Ascending Ascending !aryngeal o 5erminal Su!erfical tem!oral 2nternal ma/illary 200.Internal carotid artery anato!y: o Cervical segment Hno .rances o 'etrous segment H small !terygo!ataline to internal ma/illary o Cavernous segment H a:a carotid si!on Kives off o!talmic artery o Cere.ral segment MCA ACA Circle of -illis is !resent in com!lete form in only 20O of !ts& 201. xternal carotid to internal carotid a@ collaterals: o 2ntracranial,e/tracranial 're,willisian anastomosis Or.ital,o!talmic Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )GF Canadian Vascular Surgery Minimum Meningo,y!o!ysial Occi!ito 0BCA1 to atlantic .ranc of verte. ral #ee! Lascending cervical 0BCA1 to lower verte.ral BCA to BCA across midline Rete mira.ile o #ural arteries to .rain surface o Small inter,territorial communications Ae!tomeningeal collaterals 3etween terminal cortical .rances for main cere.ral arteries across te .order of vascular territories 202.Clinical presentations of cere.ral syndro!es: 52A , R2F duration Crescendo 52A H same s/s .ut increased fre>uency" o: .etween e!isodes& Stro:e in evolution H stars as 52A .ut e/tent of deficit and fre>uency is increasing wit overall worsening neuro status Ka;e toward side of lesionM Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )G* Canadian Vascular Surgery Minimum o 2CA H monocular i!silateral visual sym!toms !lus MCA o MCA H CA emi!aresis < emianestesia A5hasia 2 %an*( 'ind ,o"ds o L sided (e""i(o"$ D$s5hagia 2 %an*( 5"onoun%e ,o"ds, s+u""s o R ;9DED TERR9T)RT CA neglect A!ra/ia 0can9t carry out !ur!oseful movement1 o 'CA H omonymous visual field loss denial of .lindness , Anton9s syndrome o ave to ave .ilateral verte.ral occi!ital lo.e !enomenon o can9t see wit unilateral stro:eM visual allucinatinos loss of reading 0ale/ia1 confusional state amnesia discoordination b+ind, ha++u%ina(e, a+e7i%, amnes(i% o ACA H CA sensory canges ina.ility to wal: 0gait a!!ra/ia1 a!aty" mutism %an*( ,a+=, no( s5on(aneous, u"ina"$ in%on(inen( o V3 crossed findings 0i!si CN !alsy and CA e/tremity sensoryLmotor deficit1 H in .rain stem vertigo" disorientaton" dise>uili.rium s!eec !ro.lems iccu!s hi%%u5s and diseBui+ib"ium Tab+e 1QA/38 ;igns and ;$m5(oms o' 9FA/Re+a(ed 9s%hemi% E&en(s GA;FHLAR TERR9T)RT ;TM.T)M; ;9IJ; 2CA 5ransient monocular visual canges lasting a.out E,* minutes and !resenting as Amaurosis fuga/ Rarely ?orner]s syndrome 3lindness Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )GG Canadian Vascular Surgery Minimum 3lurry or foggy vision 3lind s!ots" colors" sa!es 5unnel vision 2n only )0,)*O" curtain,li:e .lindness ascending or descending trougout visual field
Rarely eadaces MCA #ifficulties in com!reension or language !roduction" difficulties !erforming motor tas:s or calculations" incoordination" num.nessLtingling on one side of .ody" wea:ness in arm and leg A!asia" head and e$e de&ia(ion (o,a"d +esion, a5"a7ia, neg+e%(, anosognosia, contralateral sensory deficit" contralateral !aresis" confusional states ACA Num.nessLtingling on one side of .ody" wea:ness of leg more tan arm" difficulties wal:ing Contralateral sensory deficit" contralateral !aresis" a5a(h$, mu(ism, "edu%ed s5on(anei($, gai( a5"a7ia, u"ina"$ in%on(inen%e 203.-isual syndro!es: o 3asicsC occi!ital corte/" ten to mid.rain" ten to ciasma" ten o!tic nerves& 're,ciasmal fi.ers H outside travels to i!silateral tem!oral retina" fi.ers su!!lying nasal retina are on te inside and cross over& o O!tic nerve severed H com!lete .lindness o Ciasm in4uryC longitudinal cut H cut inside cross over fi.ers tat su!!ly nasal retina H o .ilateral eteronymous emiano!sia H .i tem!oral .lindness transverse !artial cut into fi.ers tat travel on te outside tat su!!ly tem!oral retina H o Contralateral nasal .lindness o 'reciasm fi.ers H contralateral omonymous emiano!sia H R .rain is watcing A side H A nasal" and R tem!oral fields are affected 204.Indication for carotid duplex: o See #o!!ler notes in 2 nd sectionM o 2ndicationsC 3ruit in asym!tomatic !t Seen in *O of !ts a.ove *0 yoa Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )G+ Canadian Vascular Surgery Minimum 'resent in only 20O of !ts wit ?# significant stenosis Amaurosis fuga/ 6ocal 52A 6ollow u! of :nown Q20O stenosis in asym!tomatic #ro! attac:s 0rare1 CBA setting o CVA in candidate for CBA for OR !lanning o 2ntrao!erative assessment of CBA o CBA witout arteriogra!y o 6ollow u! after CBA 0single study at )2L)2 after surgery1 o Can trust US ifC No !ro/imal CCA irregularities No :in:sLloo!s No aneurysms Kood >uality study 2ndications for carotid angioC o Can9t trust du!le/ 0:in:" aneurysm" !ro/imal CCA irregularity1 o 2n e>uivocal du!le/ findings o #u!le/ can9t sow e/tent of disease o Sus!icion of tandem or arc lesion o Uncommon carotid !atology o 5rauma o -Lu for stent 205.ICA and CCA Doppler profile C6A H tree com!onents H o forward flow" reverse flow" forward flow& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )G8 Canadian Vascular Surgery Minimum 2CA !rofile H .i!asic .ecause of elevation of .aseline H o i&e& no reverse flow NO5 .ecause of disa!!earance of te Erd com!onent of forward systolic flow ?a!!ens .ecause of low resistance in 2CA& 2 nd H reversed H com!onent is gone Note H s!ectrum window is clear under te curve H no .roadeningM o -asington criteria H .ased on BCS5" NO5 NASCB5 angiogra!ic correlation BCS5 H outlines y!otetical normal carotid .ul. and measures stenosis wrt tis NASCB5 H com!are distal 2CA to stenosis May get negative stenosis figures Com!ared to BCS5" !redicts less severe stenosis o Angiogram H underestimates stenosis o MRA !ro.a.ly e>uivalent to du!le/ US o ?ig sensitivity study A.le to recogni;e an a.normality needed for sym!tomatic !ts o ?ig s!ecificity study Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )G% Canadian Vascular Surgery Minimum a.ile to recogni;e normal artery needed for asym!tomatic !ts 206.Carotid duplex artery stenosis criteria: %as"ington Criteria o Si;e of carotidC At .ul. 0&%F cm M" 0&%2 6 2CA 0&** cm M" 0&F% 6 o Remem.er tat it OVBRBS52MA5BS te stenosis 0BCS5" not NASCB5 criteria1 o Remem.er" tat it gives ranges tat do NO5 a!!ly for NASCB5 0+0O stenosis 1 & o May .e a!!lica.le to ACAS 03= ANK2O G0O stenosis1 o NormalC no !la>ue" smoot walls" .oundary layer se!aration in .ul. o R )* O mild S3 o )G,F%O mar:ed S3" no systolic window o *0,+%O 'SV Q)2*" '#V R)F0 cmLsec" mar:ed S3" 2CALCCA Q )&8 o 80,%%O 'SV Q)2*" '#V Q )F0 cmLsec" !oststenotic tur.ulence" 2CALCCA Q E&+ o OcclusionC no flow May .e wrong in EO of cases H ence AA-A=S confirm tis wit angio or MR2& 207.Consensus panel on 0S criteria on carotid stenosis: o 5ese are more !ractical ten -asington H .ased on Nascet tecni>ue and range of measurements of stenosisC o R*0O 'SVR)2* B#VRF0 Ratio R2 o *0,G% 'SV )2*,2E0 Visuali;ed !la>ue B#V F0,)00 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )+0 Canadian Vascular Surgery Minimum Ratio 2,F o Q+0 'SV Q 2E0 Visi.le !la>ue B#V Q )00 Ratio QF 208.Ot"er useful *elocities !easure!ent for carotids o QG0O stenosis H e/ternal Oregon validation wit angio 'SV Q2G0" B#V Q+0" ratio Q E&2& Accuracy %0O o NASCB5 Q +0O stenosis 'SV Q280" B#V Q 80" Ratio QF ''V %*O o Q80O stenosis 'SV Q2*0" ratio QF %0O accuracy for +0,%%O range o 2ntrao! du!le/ assessment of CBA Re!air if 'SVQ200 o Su.clavian artery stenosis Retrograde 0notced1 verte.ral flow o No graded 'SVs values vs occlusion for verte.ral artery flows o Verte.ral stealC See eiter reversal of flow or stalled flow 're,steal , 3ac: 0systoly1 and fort 0diastoly1 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )+) Canadian Vascular Surgery Minimum #on9t confuse wit !asic flow in verte.ral vein 209.1re2uency of Sur*eillance of known asy!pto!atic stenosis o Asym!tomatic Q G0 stenosisO 2f 'SVR)+* cmLsec 'rogression is FO over 2) monts 2mage annually 2f 'SV Q )+*O 'rogression 2GO over )F monts ?ence image > G mont 210.#ec"anis!s of stroke: RuterfordC 2scemic 080O1 H non !ainful emorragic 020O1 H !ainful o dd of 2C? trauma tumor H !rimary vs met ?5N Amyloid angio!aty AVM aneurysm 2scemicC 20,E0O are due to ma4or B/racranial and intracranial cere.ral vessels E0O are due to em.olism 0close to *0O in !ts younger F0 yoa1 o Unli:e carotid origin" tese are NO5 territorial F0O of stro:e H no :nown cause Sro:es a!!en .ecause ofC Bm.olism 5rom.osis o B/tracranial o 2ntracranial lacunar ?y!o!erfusion Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )+2 Canadian Vascular Surgery Minimum o 6low related !enomenon are due to decreased cardiac out!ut and occlusion 'atology leading to stro:eC Aterosclerosis %0O o Artery,artery ateroem.olism 0MC1 o trom.osis Bm.olism o Cardiac 0A6" !ost M2" valve1 o Q *0O in !ts R*0 yoa OterC o 6M# o Iin:s < loo!s o 5raumatic occlusion 2ntimal dissection o 2nflammatory angio!aty ta:ayasu" KCA o Aneurysm o 2ntracranial vessel diseaseC Vasculalitis 'AN -eird and wonderfulC moyamoya" fi.rinoid necrosis" amyloidosis" arteritis o C5# o allergic" granulomaout" infectious o '& )88E
Summary of Non,ASC causesC 6M#L:in:sLdissectionsLarteritisLlacunar 211.$a. and in*estigations for &IA: NB- definitionC a ("ansien( e5isode o' neu"o+ogi%a+ d$s'un%(ion %aused b$ 'o%a+ b"ain, s5ina+/%o"d, o" "e(ina+ is%hemia, ,i(hou( a%u(e in'a"%(ion& NO5B H no more 2F time line is given ##C 'artial com!le/ sei;ure Com!licated migraine #emylienating !rocess Meta.olic 0glucose" liver" lyte a.normality1 'syciatric , conversion disorder Sro:e in youngC F0O are cry!togenic em.olism Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )+E Canadian Vascular Surgery Minimum #issection 6M# Moyamoya C5C 55' y!ercoag 'reliminary 3-C c.c 0!lt" R3C1" Cr gluc" ?gA)C" li!id !rofile" BSR fi.rinogen" omocystein" '5L'55L2NR drug screen" reum 0R6" ANA" A'A" lu!us1" y!ercoag , if young o 6VA" !n 202)0" A5 def" fi.rinogen" omo" ACALAAC" !n C<S" 'A2,)" li!id !rofile and li!o!rotein a& rLo mimic:ersC cec: lytes" gluc" A65s" cardiac screenLolter" 26 BCK is a.normal" order BC?O&
2deally di''usion ,eigh(ed MR9 of te ead" if not availa.le C5 ead o According to te latest recommendations of te A?ALASA 200%
Wh$ FTV (o "o SOA emorrage" old stro:es" lacunar stro:es" cec: laterality 0and li:eliood of em.olic disease1& owever" #- MR2 is .est for 52As&&& #o!!lerLimaging H witin 2F .y guidelines" accredited la. 2f !t ad stro:eC t'A H indicated witin E ours of stro:e" not later& Sei;ures is contraindication to t'A& Maintain slig y!ertension" no y!otension Anti!latelets and statins" no e!arin& Urgent studies 0as for 52A1 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )+F Canadian Vascular Surgery Minimum
AsideC Auditory evo:ed !otentials H only good for diagnosis of demyelinating disease 0e&g& MS1" not for anatomic locali;ation& Only E0,*0O of CVAs are !receded .y 52A Mortality of initial stro:e E0O o Second stro:e E*O o Su.se>uent stro:es G*O G monts !ost stro:e H o *0O ave residual deficit" o 2*O non,am.ulatory" o u! to 20O a!asic" o 2*O re>uire care" o E0O de!ressed Stro:e in evolutionC o Mortality 20,80O o Com!lete Recovery wit medical tera!y FO o Recovery wit surgery H u! to +0O Asym!tomatic stenosisC o Seen in E0O Q*0yoa o 80O of stenosis !rogress .ut !rognosis is generally .enign 2f Q80O wit ris: factors u! to E*O ris: of 52ALstro:eLocclusion at G mots" FGO at )2 monts 3ruits o Seen in *O of Q*0yoa o Only 20O of .ruits are associated wit Q*0O stenosis o Only alf of ?# significant stenosis ave .ruit o Stronger !redictor of CA# Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )+* Canadian Vascular Surgery Minimum
212.Recurrent C-A after &IA or C-A: o Stro:e after 52A ?igest in te first 2 wee:s Overall GO !er year )0O ) year" )GO at 2 years" 2GO at E years" ten declinesM Stratifiation of 52A ris:C if ris: factors !resentC o AUQG0 yoa" o 3U3' Q)F0L%0& o ClinicalUemis!eric vs monocular" o #Uduration Q ) our" o #U#M ris: of recurrence may .e as ig as 8O in 2 days according to A3C# 2 criteria 5otal scores ranged from 0 0lowest ris:1 to + 0igest ris:1& Stro:e ris: at 2 days" + days" and %0 daysC Scores 0,EC low ris:
Scores F,*C moderate ris: Scores G,+C ig ris: Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )+G Canadian Vascular Surgery Minimum o Recurrent CVA after CVAC %O !er year" steadyM !& )880 ) st year CVA recurrence Annual recurrence Recurrence declinesD 'ost CBA annual recurrenceD CVA )0O %O No 2O 52A )0O GO =es R)O asym!tomatic , 2,*O , 0&EO Moores dataC 2f ulcer is Q F0 mm 2 and cavernous H ten annual stro:e may .e as ig as +&*O" even wen no significant stenosis is !resentM Controversial& 213.&i!ing of CA wit" respect to C-A After 52A H calculate A3C#2 rates and may offer surgery same admission After CVA H if neurologically recovered" witin 2 to F wee:s& 200% ?arvard review course recommends witin 2 wee:s .ut tere are no RC5 to su!!ort tisM Old adageC 7if even a!!ened witing a day" fi/ in a dayN if witin wee:" fi/ in a wee:N if witin mont H fi/ in a mont8 H may ave some valueM 214.Contraindications to CA o Carotid aneurysm o Ma4or !revious stro:e wit significant neurologic dysfunction o Acute ma4or stro:e 'remature .lood flow increase may e/acer.ate deficitC o Area lost its9 autoregulatory a.ilities o 3lood .rain .arrier is disru!ted Bdema 2ntracranial .leed Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )++ Canadian Vascular Surgery Minimum ?ence" may ave to wait u! G wee:s ten rLa neuro status& 2f com!lete recovery is seen earlier" Ruterford suggests may o!erate .efore GL*2 215.Co!plications of CA: M<M a.out GO for sym!tomatic and EO for asym!tomaticC 2MMB#2A5BC neuro , !erio! stro:eLy!er!erfusion" o see y!er!erfusion on E,+ day local , .leedLinfectionLCranial n 0y!oglossal" marginal1 H most reversi.le " systemic , ?# insta.ilityLM2& #2S5AN5 H restenosis , )0O at 2 y" )+O at )0 y , int y!er!lasia vs ASC&&& !atc reduces incidence& 'atc aneurysm 216.Conduct of CA: Koals H remove !la>ue" re!air artery" avoid com!lications ConsentC indications" ris: and .enefit discussion 3eac cair !osition" nec: e/tended" ead turned Regional anestetic" monitor CA arm activity and fre>uent neuro cec:s Bar,lo.e H to ni!!le !re! Cut along ant .order of SCM o S:in o 'latysma o Reflect SCM laterally Ko in front of 4ugular vein" 2# facial vein o Iey to .ifurcation Bnter seat" !reserve ansa and vagus #issect 7!atient away from artery8 Aoo! CCA" BCA" su! tyroid" 2CA o 'reserve y!oglossal 2n4ect .ifurcation wit lidocain" don9t dissect tere As: neuro to maintain 3'" neuro cec:" e!arin" circulation time 5est clam! 2CA wit .a:er clam!" neuro cec: Clam! CCA" BCA" cli! su! tyroid CCA,.ul.,!ro/ 2CA longitudinal arteriotomy 'enfield or #allar tool !lus Aower 5ransect !la>ue in CCA" wor: it u! around BCA orifice" transect at te .ase of te 2CA Bversion BCA endarterectomy Continue BA !lane to 2CA" feater out or tac: wit +C0 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )+8 Canadian Vascular Surgery Minimum Clean surface 'atc Unclam! 2CA H ten reclam! Unclam! BCA and CCA 6inally unclam! 2CA" neuro cec: 'rotamine" emostasis" consider drain o Aess ematoma Close !latysma Sta!les o Remove tese 'O# ) and re!lace wit stereostri!s& 217.Indication for CA endarterecto!y: o Occluded i!silateral 2CA wit ongoing sym!toms refererra.le to te side were BCA stenosis is found Am!utate 2CA" flus close after BCA endarterectomy 218.Difficult access to ICA: "ig" ICA/ difficult ICA o Standard access H u!!er tird of C2 Cut sternocleidomastoid .ranc of occi!ital artery will allow to lift y!oglossal u! B/tend incision to mastoid o #ivide !osterior digastrics m H middle tird of C) Mo.ili;e and elevate lower !ole of !arotid gland 5ransect SCM at mastoid !rocess o Su.la/ate 5M$ 0call for ead and nec: surgeon to el!1 #on9t dislocate Need nasotraceal intu.ation o Resect styloid !rocess H u!!er alf of C) in *0O of cases o Cut of !osterior !ortion of te mandi.le ramus H gets you a.ove C) in )00O of cases Aateral mandi.ulectomy !reserve inf& Alveolar nerve o 6inally" going retro4ugular on initial a!!roac e/!osing te carotid can get you sur!risingly igM 0#r& ?a44arLAewis1 219.(er*es encountered during CA + 2n4ury rate H overall )0O&&& Most are transient& o ?y!oglossal FO , tongue deviation" swallowing Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )+% Canadian Vascular Surgery Minimum MC in NascetLruterford o Vagus EO , oarse voice" airway !ro.lems Osler course ma:e it most common in4ury Very often overloo:ed" ence ma:ing it li:ely te MC CN in4ury o Marginal mandi.ular 2O , droo!ing corner of mout" drooling o Kreater auricular H num. ear o Su!erior laryngeal H sustain ig !itc o S!inal accessory H soulder dro! o Sym!atetic cain H orner9s 220.(ascet findings: 2 year results Asa vs ASALCBA o i&e& NO statins& Medical management is outdated& Ratio of stenosis diameter to normal !ro/imal 2CA 2GO vs %O for +0,%%O" o NN5 G for R +* yoa o NN5 E for !ts Q +* yoa o ma4orLfatal stro:e )EO vs EO ARR )0O 22O vs )GO for *0,G%O" NN5 )+ o No difference in ma4orLfatal stro:e Need com!lication rate R *O AsideC BC5 , Q +0O stenosis ?ig E0 days surgical stro:e of +&*O E year GO vs ))O fatalLdisa.ling stro:e in favor of surgery Dina+ %on%+usion- )& CBA is offered in all sym!tomatic !ts wit severe stenosis 0Q +0O1 a& 'ts Q +* yoa ave most .enefit 2& 2n ig,moderate stenosis 0*0,+0O1C a& for male H if good o!erative ris: for OR .& for women H only for !ts wit !ersisting sym!toms unres!onsive to medical tera!y" emis!eric 52A AN# ris: 'V# factors c& 5ere is no reduction in fatalLdisa.ling stro:es in Nascet study AsideC if see clam! defect on com!letion angio H leave it alone" don9t fi/ it unless it is ?# significant" it will eal& 0Osler1 D"8 H8W8M8 <a"ne((- The a55"o5"ia(e use o' %a"o(id enda"(e"e%(om$8 WAMF, 3003 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )80 Canadian Vascular Surgery Minimum ;$m5(oma(i% > L0K s(enosis8 All !ts are .etter off wit surgery" .utM Most .enefit seen inC ?ealty elderly !ts Q +* yoa ?emis!eric 52A 0NO5 monocular1 'ts wit tandem e/tracranial and intracranial lesions 'ts witout angiogra!ic evidence of collateral !atways 'erio!erative ris: is iger in te following !ts" 3U5 surgery is still .eneficialC -ides!read leu:oaraiosis o Significant ris: factor for stro:e o 'oorly defined y!odense wite matter lesions Unli:e sar!ly defined infracts o Overall .enefit is smaller Occlusion of CA carotid artery 2ntraluminal trom.us ;$m5(oma(i% R L0K s(enosis- 6or most .enefit smaller& 5e following !ts may .e ?ARMB#" !articularly if tey ave few Ris: factors C 'ts wit monocular 52A -omen 5e !resence of te following R6 increase .enefitC o Q+* yoa o Male o 2C CaveatsC CBA carries 2O incidence of #isa.ling stro:e& SoC 'recise measurement of stenosis is essential 6ollow e/clusion criteriaC o 2m!ending organ failiure o Serious cardiac dysfunction o Aate stage cancer 5ese !ts not li:ely to .enefitM 221.Asy!pto!atic Carotid artery stenosis and ACAS findings: o E% centers" elite surgeons o Kood ris: !ts" mostly men o * year results o Most events occur after E years Stat significance only after * t year Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )8) Canadian Vascular Surgery Minimum o Stenosis Q G0 O 3ut NO de!endence .etween e/tent of stenosis vs .enefit ))O vs *O" ARR GO" NN5 )+ men )2&)O vs F&)O , ARR 8O ,omen 88LK &s L8QK ARR 18MK no( s(a( signi'i%an( o 6atal stro:e and disa.ling stro:e H no stat difference o Need com!lication rate R EO o 6emales or Q 80 yoa li:ely no .enefit o Recommended for good ris: male !ts wit E year life e/!ectancy" at least G0O stenosis& Results for women less certain& AF;T 'indings- h((5-s("o=e8ahaPou"na+s8o"g%gi%on(en('u++s("o=eahaXQM10343M Aarger study community surgeons" no elite re>uirements te only study to sow stat sig difference in fatalLdisa.ling stro:e of 2&*O&& females ave 52N= stat significant .enefit" uncertain clinical .enefit ;o ,ou+d 9 o''e" su"ge"$ on as$m5(oma(i% sideV ris: of stro:e for asymtomatic R 80O is generally low o ),2OLyear" F2* !t" sta.le *0,+%O stenosis * year cumulative ris: of event is *&FO o Recommendation to consider OR a.ove 80O stenosis only NN5 is 8E according to 3arnett !a!er 0) O yearly" i su!!ose1 )+ according to NB$M review 0for *O ARR over * years&&&1& Ris: of an event wit stenosis a.ove 80O , may .e as ig as ))O !er year&&&&& te greater te stenosis" te more R6 tere is" te greater te incidence of stro:e&& o some re!ort incidence of stro:e in Q80O as ig as E*O at GL)2 also" only E0,*0O of !ts wit CVA ave an antedecent 52A o so can9t rely on waiting for reversi.le sym!toms of 52A as a warning system for incoming stro:eM ;(i++, (he mos( %ommon e&en( in AFT;AFA; 2 M9, J)T s("o=e88 AFA; a%Bui"ed s(a(is(i%a+ signi'i%an%e 'o" s("o=es on+$ a'(e" a sma++ bu"s( o' s("o=es a'(e" M (h $ea" o' 'o++o, u5 o i8e8 no signi'i%an%e ,ou+d ha&e been "ea%hed i' on+$ 'o++o,ed 'o" 4 $ea"s o on+$ 1Q/13 o' is%hemi% s("o=es ,e"e "e'e"ab+e (o i5si+a(e"a+ %a"o(id s(enosis8 Unfortunately" te very same factors tat ma:e stro:e more li:ely witout an o!eration" also increase !erio!erative ris: of stro:eM
Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )82 Canadian Vascular Surgery Minimum 2n ACAS" te following factors increased 5e"io5e"a(i&e "is= o' s("o=e, T9A, o" dea(h o Anatomical factorsC Contralateral carotid stenosis QG0O Contralateral si!on stenosis o Clinical factorsC 'rev CVA ?y!ertension #M 6emale gender Age Q+* yoa C?6 o 'rocedural factorsC Com.ined carotid,cardiac surgery i&e8 FL disease, .GD 'a%(o"s, 'ema+e, age >LM At te same time" te following factors increase ris: of aving a stro:e in asym!tomatic stenosis if followed non,o!erativelyC o Anatomical factorsC Soft" ecolucent !la>ues CA 2CA occlusion Silent i!silateral infarction on C5 o Clinical factorsC ?tn #m Smo:ing ?y!erli!idimia ?y!eromocystein 98e8 .GD "is= 'a%(o"s: so te decision to do surgery in asym!tomatics is not an easy oneM o on te one and" multi!le R6 ma:e !ts more !rone to stro:e 0from .aseline 2O to as ig as ))O1 o on te oter" te very same R6 ma:e !t more !rone to !erio!erative CVALdeat& Also" te .enefits of CBA do not get reali;ed until E rd year !ost o! and it does not a!!ear to .e cost effective in 80 year olds" or females Medical tera!y is getting .etter& $u!iter trial sowed *0O reduction in stro:es and M2s wit statin tera!y at 2 years in asym!tomatic !ts& Fon%+usion- o 2f !t as less tan E year life e/!ectancy" CA occlusionLstenosis" Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )8E Canadian Vascular Surgery Minimum as 6B- vascular R6" is a female under 80O stenosis" M medical tera!y is .eneficial& 'articularly statins 0$u!iter trial1& o -o is an ideal asym!tomatic candidate for CBAD male R +* yoa" Q80O stenosis R6 for 'V# No contralateral occlusion
o 2f decision to o!erate is made" it is im!erative for te o!erator to ave less tan EO com.ined M<M stro:e ris: to ensure gradual reali;ation of GO 0at most1 of a.solute ris: reduction over te ne/t several years&&& o So for te e/am intent" unless you can !rove to te e/aminer your record of asym!tomatic CBA is low and you understand te ris: variation wit different R6 trown in te mi/" 29d .e careful suggesting CBA for an asym!tomatic !tM& Carotid Stent , still investigational& Crest Hfor sym!tomatic !ts is not out yetM Reserved for ig ris: Sym!tomatic !ts 0tecnically or !ysiologically1& 6or asym!tomatic H use stent in off la.le investigational setting only 222.Carotid patc"ing + ad*antages and disad*antages: o #isadvantagesC Aonger clam! time 'otential .low out if use vein 'otential infection if use !rostetic o Advantages Aower restenosis rate Reduced acute carotid trom.osis Reduced !erio! neurologic rate o All tese were suggested .y Cocrane 200G metaanalysis" F0 !erio!erative stro:es are !revented !er )000 !tsM No RC5 done& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )8F Canadian Vascular Surgery Minimum Com!lications of CBAC 2mmediateC o Neuro deat ?y!er!erfusion stro:e Bm.olismLtrom.osis #isa.ling 2O 2f !t is Sym!tomatic ris: is u! to GO" if asym!tomatic EO o AocalC CN in4ury Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )8* Canadian Vascular Surgery Minimum 3leeding -ound deiscence infection o SystemicC ?# insta.ility M2 Aong,termC o Recurrent stro:e A65BR re!air Annual ris: 0&EO if asym!tomatic 2O if sym!totic !ost CVA R)O if sym!tomatic !ost 52A o Recurrent stenosis o 'atc .low outLaneurysm 223.Recurrent stenosis after CA: #efined as recurrent stenosis Q+0O& o 2? in first 2 years" ten aterosclerosis o MetaanalysisC )0O at 2 years" )+O at )* years& ?igest in first year" ten low rate Kenerally )O !er year o Only one tird to one alf are sym!tomatic o 2ncidence Significantly reduced .y !atcingC down to 2O at 2 years !&2)0E acas H +0,80O reduction wit !atcing o 2f sym!tomatic" consider longevity AN# nature of lesionC At * years H +FO" at )0 years F2O Most lesions are 2?" not atero Aow ris: for ateroem.olism o Management o!tions includeC Aggressive medical tera!y o #i!iridomole and ASA is .etter tan 'lavi/ and ASA o Statins 0$u!iter trial1 CBAP!atc ResectionPautologous inter!osition grafting CAS Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )8G Canadian Vascular Surgery Minimum o 2f asym!tomatic" o!tions includeC #u!!le/ follow,u! H )LE of lesions will regress wit remodeling OR H very rarely as natural / is .enign and re!eat OR is mor.id affair 224. Carotid s"unt co!plications? Sunt ty!es H outlying 0'ruitt,2noara1 vs inline 0$avid1 Need *0 mlL)00 mgLmin of .rain tissue !erfusion during clam!ing #issection Bm.oli;ation Migration 'oor distal end!oint managment 3loc:age .y de.ris May forgo sunt if Q*0 mm?g .ac: !ressure& 2f !t ad !revious CVA use sunt routinely 0unless doing it awa:e1 H !& )%8)& $avid" Argyle" 'ruitt,2nnoara& 225.CA and CA,7 + decision !aking in *asc surgery: p@ CD CA3K .y itself causes cere.ral ateroem.olism Ris: of stro:e for CA3K alone is G&+O in ?ert;er RC5 o Seems ig" .ut tat9s wat 7#ecision ma:ing in Vascular Surgery8 state Sorting out wat is res!onsi.le for te event !ost com.ined re!air is difficult 6irst" define ig vs low neuro ris: o ?ig H tese need to .e addressed eiter .efore or during CA3K .ilateral severe 0Q80O1 asym!tomatic stenosis severe sym!tomatic unilateral severe asym!tomatic wit CA occlusion o Aow ris: H unilateral severe asy!tomaticC tis can wait and followed on du!le/ Secondly" define ?ig vs low Cardiac ris: o Unsta.le angina ?2K? ris: o Sta.le angina AO- ris: Com.inations to .e consideredC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )8+ Canadian Vascular Surgery Minimum 'ts wic is ?ig neuro and ?ig Cardiac ris:C o Controversial" now tat CAS and 'C2 are availa.le o 5raditionally Com.ined o!enC Acce!t ig ris: of M<M com.ined )*, )+O o OrMAocal CBA ten F8 CA3K 5at9s wat 29d suggest on my e/am o OrM 'C2 and CBALCAS com.inedLstaged o No good data to su!!ort one or te oter 'ts wit ?ig neuro and Aow cardiacC o CBA first" ten CA3K in F,G wee:s o Recent review 0aug 2008 .y Claggett1 CAS was worse tan CBA for sym!tomatic" CAS .etter tan CBA for asym!tomatic com.inations wit CA3K Aow neuro and ?ig cardiacC o Cardiac first" ten monitor carotid o Com.ined ris: of com!lications sould .e less tan 8O 2f can assure tis" may do com.ined" oterwise stage Aow neuro and Aow cardiac ris:C o May do eiter" de!ending on te institution results H com.ined vs staged 226.CAS trials: 2nitial early deat and mortality were )0O" .ut current series 0)+"000 !ts1 H *O& Recurrent stenosisC )0O at 2F mont& 'redis!osing factorsC 6emale CR' elevation witin F8 Redidual !ost !rocedural stenosis 2ncom!lete a!!ostion Age Q +* ?ig ris: !tsC !& 20)0 .h$sio+ogi% %"i(e"ia- o Severe CA# re>uiring 'C2 or CA3K o ?/ of C?6 o Severe CO'# re>uiring ome O2 and 6BV ) R20O !redicted o Severe renal failure 0 Cr Q E or 2F01 Ana(omi% %"i(e"ia- Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )88 Canadian Vascular Surgery Minimum o 'rior CBA wit restenosis o CA vocal cord !aralysis o Surgically inaccessi.le lesion H atLa.ove C2" inferior to clavicle o Radiation induced stenosis o 'rior i!silateral radical nec: dissection SA''?2RB trial of CAS in ?2K? R2SI !atients randomi;ed to CAS 0n U )G+1 or CBA 0n U )G+ 1 com.ined end!oint of stro:e" deat" and M2& y!otesis tat CAS was not inferior to CBA Most of te randomi;ed !atients were asym!tomatic H +0O in eac grou! At E0 day H more M2 in surgery grou! F&F vs 8 O" te rest e>ual& E0 day te ris: of stro:e CAS E&)O" CBA E&EO NO #266BRBNCB E0 day Mortality CAS , 0&GO vs CBA 2&0O P U 0&EG NO #266BRBNCB E0 day M2 CBA , G&GO vs CAS grou! 0F&FO1" P R 0&0*1& o most of te M2s were non,S" o identified on routine !ost!rocedure la.oratory studies" E0 day com.ined end!oint deatLstro:eLM2 sameC CAS , F&FO vs CBA, %&%O P U 0&08 ) year dataC o Ma4or i!silateral sto:e H CAS 0O vs CBA E&*O& P U 0&02 o M2 , CAS 2&*O vs CBA 8&)O& P U 0&0E 1 $ea" %ombined end5oin( a( 1 $ea" 'a&o"ed (he FA; g"ou5 o 1380K &s8 3081K P = 080M Fon%+usion 2 FA; is non/in'e"io":8 5e ARC?eR study of a stent and !rotection devicea registry of ig,ris: !atients te com!osite end!oint 0stro:eLdeatLM21 was +&+O" o included a *&EO stro:e ris:N o te ris: of stro:e or deat was G&GO at E0 days& o 'atients aving CAS for restenosis following CBA ad an e/tremely low ris: of stro:e 00&+O1N o tose !atients wit end,stage renal disease ad an e/traordinarily ig ris: 028O1& o Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )8% Canadian Vascular Surgery Minimum 5e BVA,ES study o Bndarterectomy versus Angio!lasty in 'atients wit Severe Sym!tomatic Carotid Stenosis o Randomi;ed" o NO5 ?2K? R2SI sym!tomatic !atients ,i(h >A0K %a"o(id stenosis to CAS or CBA o Re>uirementsC vascular surgeon min 2* CBAs 0wit no u!!er limit of M2LCVA1 interventional !ysician )2 CAS !rocedures OR E* interventions in te su!ra,aortic trun:s" at least * of wic were on carotid artery at least two !rocedures wit a new device o !rimary end !ointC com!osite of stro:e and deat at E0 days& o 2G) !atients underwent CAS and 2*% ad CBA and were analy;ed for !rimary outcome measures& o trial was designed to sow noninferiority o stenting was found to carry a greater ris: tan endarterectomy& o 5e E0,day incidence of any stro:e or deatC E&%O after CBA and %&GO after CAS disa.ling stro:e or deatC )&*O after CBA and E&FO after CAS i8e8 ARR 3K o No stat difference in Systemic com!lications or local com!lications o Cranial nerve in4ury was more common after CBA 0+&+O1& o no difference in results from ig vs low enrolling centers o no difference .tw e/!erienced vs less e/!erienced o!erators 5e trial was sto!!ed !rematurely after enrollment of *2+ !atients .ecause of 7.ot safety and futility"8 as CAS carried significantly iger ris: tan CBA& CriticismC o 20 !ts in stent grou! were done witout cere.ral !rotection o * different stents" + different em.olic !rotection devices used o Aow e/!erience of interventionalist was re>uired SummaryC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )%0 Canadian Vascular Surgery Minimum So BVAE H o no ig ris:" o CBA FO vs CAS %&GO fatalLdisa.ling ,)&* vs E&* in favor of surgery Sa!!ire H o ig ris: o CBA 20O vs CAS )2O in favor of CAS S'ACB trial o Stent,!rotected angio!lasty versus carotid endarterectomy in sym!tomatic !atients o )200 sym!tomatic !atients o 52A or moderate stro:e witin )80 days o randomi;ed to CAS or CBA o Bm.olic !rotection used only in 2+O of !ts o 5e !rimary end!oints o i!silateral iscemic stro:e or deat witin E0 days of te !rocedure o deat or stro:e was G&8FO in te CAS grou! and G&EFO in te CBA grou!& o 5e autors concluded tat te study failed to !rove te non,inferiority of CAS com!ared wit CBA 0!,value of 0&0%1 o 2m!ortant age related outcomes of stentingC o No difference in stro:e rate in less tan +* yo o ))O vs +O in stro:e in Q +* year olds 0in favor of CBA1 Crest trialC 6inal results are still !ending Aead in !ase resulsC o morality and stro:e in CAS E&FO for asym!tomatic and *&GO for sym!tomatic o Outcome eavily de!endent on ageC Age 0N1 Stro:eLdeat O RG0 0)201 2 0)&+O1 G0,G% 022%1 E0)&EO1 +0,+% 0E0)1 )G0*&EO1 Q80 0%%1 )2 0)2&)O1 'ending studies H 2nternational Carotid Stending study 02CSS1 H only sym!tomatic !ts Asym!tomatic Carotid Surgery 5rial `2 0AC521 Asym!tomatic Carotic 5rial 0AC5)1 MetaanalysisC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )%) Canadian Vascular Surgery Minimum Aue.:e9s H 200+ H E0 day stro:e or deat )&E%O 3amanandam9s H 2008 H E0 day ris: of stro:e )&E8O 5ese results" wen com!ared to CBA are marginally iger& 228.$ ICA occlusion@ %"at do do? See if sym!tomatic& 2f yesC Confirm flow distri.ution wit Jenon C5L'B5 2f definite y!o!erfusion" may .e one of te rare cases of e/tracranial to intracranial .y!ass o Anoter indication for BCL2C .y!ass, moyamoya and ig carotid aneurysm tat can9t .e ligated and reconstructed at nec: Recogni;ed tat s/s are emodynamic" NO5 em.olic o Oterwise" all tat need to do" ligate origin of 2CA and o!en u! BCA COSS study !ending in 200%" #ecem.er 'revious study of BC2C3 study in )%8G H .y!ass U medical tera!yM 229. -erte.ral insufficiency: ## of synco!yC Stro:e V32 Cardiogenic soc: ?y!otensive state B!ile!tic sei;ure Meta.lic state Rull out o AocalC Aa.yrintine Su.clavian steal o SystemicC Ortostatic dro! Meds B/trinsic com!ression Anemia C?6 Arrytmia Malfunctioning !acema:er Venomotor !aralysis of dia.etics 3rain tumor Usually see immediate s/s wit ra!id ead sa:ing or turning if coclearvesti.ular !ro.lems are te source of sym!toms& 2f !ro.lems wit com!ression of verte.ral artery and low flow H see delay of several seconds" !osition de!endent& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )%2 Canadian Vascular Surgery Minimum StudiesC MR2 0.rainstem infarct1" angio 0!ositional and cranio,caudal loading1" ?olter V32C includes s/s and stro:es S/sC Synco!y #i!lo!ia Vertigo Ata/ia E0O microem.oli;ation H !redominant cause of stro:es o 6rom innominate" su.clavian" verte.ral G0O Aow flow H !redominant cause of s/s .ut not stro:es o 'la>ue o Osteo!yte Concomitant verte.ral and carotid a& re!airC ?as to .e on te same side VA is dominant" stenosed Q +*O OR res!onsi.le for em.oli 't understands tat ris: of com!lications e/ceeds aggreagated M<M for individual re!air of carotid and verte.ral lesion 0Ruterford com!anion1& V) H most common stenosis at orifice due to aterosclerosis V2 H most common !atology H com!ression VE H MC !atology H trauma" 6M#" dissection& Stays o!en due to collaterals from occi!ital a& VF,surgically incaccessi.le 230.Re*asculari>ation of *erte.ral artery: Su.clavian .y!ass 0rare1 Carotid trans!osition H most common" for V) lesssions Carotid .y!ass H for V2 lesions" at te .ase of te s:ull& o Off common o Off e/ternal o Off occi!ital o Off cervical 2CA 231.Descri.e steal/ outline treat!ent: 6or steal" one needs to aveC o #ominant verte.ral a& affected 0M0K Le'(" 2*O .ot or R1 o 'ro/imal su.clavian 0or innominate on te R1 stenosis Reduced inflow Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )%E Canadian Vascular Surgery Minimum o #ecreased !eri!eral resistance in u!!er e/tremity 0due to e/ercise1 causes reversal of flow in verte.ral artery& 2f artery is dominant" significant verte.ro,.asilar insufficiency is seen 5o diagnose stealC o #u!le/ o will ave same direction in CCA and su.clavian 0red1 " .ut reversed in verte.ral 0.lue1& 5o treat suclvian steal is to treat !ro/imal su.clavian stenosisC Bndo '5A" dodgy as may occludeLdissect verte.ralLA2MALR2MA origin O!enC 5ranstoracic o 5rom.o,endareterectomy o Ascending Aorto innominateLsu.lavian .y!ass B/tratoracicC o Carotid su.clavian trans!osition o Carotid su.clavian .y!ass o A/illo,a/illary 3' 0rare" des!ised .y !urists1 o 6emor,Qa/illary 3' 0very des!erate and rare1 232.,ranc"es of su.cla*ian artery: o Verte.ral o 5yrocervical trun: o Costocervical trun: o 2nternal mammary o #escending or #orsal sca!ular 0*0O of time1 233.,ranc"es of axillary artery: o ) st !art su!reme toracic o 2 nd !art toracoacromial lateral toracic o E rd !art su.sca!ular !osterior umeral circumfle/ anterior umeral circumfle/ Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )%F Canadian Vascular Surgery Minimum 234.1eatures of spontaneous carotid dissection: CauseC 6M#" marfan" Blers,#anlos" muco!olysacaridosis o 3lunt traumaC im!ortant" .ut clearly tis is not S'ON5ANBOUS category Most diagnosed !ost factum after neuro deficit set in =ounger !ts Clinically seeC o ?eadace PL, nec: !ain o oculosym!atetic syndrome o Neuro deficitC Stro:eL52ALSA? 'alsies of lower CN 0V22" 2J" J" J221 o Com.inations for te a.ove tree Unilateral eadace PL, 2!silateral oculosym!atetic syndrome delayed focal neuro deficit Angiogra!icallyC A!!ears as 7string sign8 luminal smoot stenosis ta!ered occlusion" distal .ranc occlusion low flow in MCA a.ru!t reconstitution of lumen !seudoaneurysm of e/tracranial arterial segment 5reatmentC USUAAA= medical H Anticoagulation o e!,Qwarf E monts o reimage at E monts if resolved" ASA if not H E monts of anticoag" re!eat dril surgical H not common trom.ectomy" !rogressive intraluminal dilation" endarterectomy" intimectomy" graft inter!osition vs ligate vs BCL2C .y!ass 'rognosisC 2f no sym!toms or mild H %0O recovery to good function& 2f sym!toms H F0O&&& See treatment of .lunt carotid in4ury in 5rauma Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )%* Canadian Vascular Surgery Minimum 235.Carotid 1#D: Most common distal 2CA o #o!!ler may miss it *O ris: of stro:e over * years H i&e& don9t treat asym!tomatics ?ave )0,*0O incidence of intracranial aneurysm H always cec: for tese and fi/ !ro!ylactically ?ave 8,F0O incidicence of renal a& involvement 236.xtracranial Carotic artery aneury!s: ## H dilated tortuous su.clavian and !ro/imal CCA o Btiology Aterosclosis +0O 5rauma H !enetrating and .lunt #issection 6M# 'ost CBA wit vein !atc angio!lasty 2nfection H used to .e most common cause" from tonislitis Media !ro.lemC Marfan syndrome Cystic medial necrosis 2dio!atic medial arterio!aty o Mc location H CCA at .ifurcation" 2 nd mc H su.clavian& o S/s and signs 'ulsatile mass in nec: or tonsilar fossa Com!ressionC Auricular !ain #ys!agia ?orner9s syndrome H com!ression of stellate ganglion 52A or stro:es ?emorrageC RARB ##C Iin:ed Lcoiled artery o Carotic :in:s H F times more common in females o Coils H more common in :ids Carotid .ody tumor Non,vascular nec: tumor 2nvestigationsC o #u!le/" angio" C5 o 2f distal 2CA involved H .alloon occlusion test H Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )%G Canadian Vascular Surgery Minimum E0 min occlusion and assessment of neurologic status as !re!aration for ligation 3ac: !ressure Q*0 mm ?gH safe to ligateM 5/C Resect and restore arterial continuity for CCA and !ro/imal 2CA lesions #istal 2CA o Bndo 0stent" em.oli;ation1 o O!en ligation H only if .ac: !ressure is Q *0 mm ?g and o: occlusion test Iee! !t anticoagualted for )0L+ to minimi;e trom.us !ro!agation 3y!ass H consider e/tra,intracrainial .y!ass if failed .alloon occlusion test& Note" tat emodynamic results of B2C3 are inferior to carotid re!air 237.Carotid .ody tu!or: o Arises from afferent ganglion of Klosso!aryngeal n& o 'araganglioma" cemoductoma o Cemorece!tor res!onsive to y!o/ia" y!ercar!nia" acidosis if stimulated" will increase RR" tidal volume" ?R" 3'" vasoconstriction" catecolamine release o Bm.ryologyC Neural crest ectoderm and mesoderm tat migrated along te afferent nerves o Autosomal dominant ineritance" .ut most s!oradic o *O guidelineC Metastatic 3iocemically active H !eoM 3ilateral 0E0O of tese are familial1 o May .e !art of MBN ) and 2 o #ifferentiate from y!er!lasia in ig altitude dwellers o On e/am H !ulsatile" not e/!ansile" can move it sideways .ut not u! and down 06ontain sign1 o Sensitive to rads .ut te only definitive control is surgery Sam.lin classificationC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )%+ Canadian Vascular Surgery Minimum #is!laced Com!ressed Bncased Clear off 2CA" ten resect wit BCA& See Oral e/am file& 238. Inner*ation of carotid .ody: o afferent in!ut to te reticular formation in te medulla via glosso!arengyal n& o Connects C3 to .rain stem so tat it can res!ond to y!o/ia 0!rimarily1" and 0lesser degree1 y!ercar.iaLacidosis o Stimulation !roduces increased RR" 3'" vasoconstriction MESENTERIC ISCHEMIA: 239.%"at are t"e non)at"erosclerotic causes of c"ronic !esenteric isc"e!ia? o Aortic dissection o 6M# o Radiation in4ury o 3uerger9s o #rugs H Cocaine" ergot o Bm.olism 6rom A6 6rom aneurysm o vasculitis 5a:ayasu Neurofi.romatosis Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )%8 Canadian Vascular Surgery Minimum 5ese form middle aortic syndrome Reumatoid artritis SAB 'AN 240.Causes of intestinal isc"e!ia: Bm.olus 0most common1 o Sudden o Inown A6LM2Lsource of em.olism o No !receding K2 / o #iarrea and a.do !ain 5rom.osis o Kradual o 'receding / of cronic !ro.lems o #iarrea 0mala.sor.tion" /ylo;e test1 o Kasless a.domen on J,ray o Collaterals on angio" orificial o.struction Non,occlusive o #ue to cardical failure" se!tic soc:" dialysis" digitalis li:e drugs ;("ing o' sausages on angio AJD 5"uning o' a"(e"ia+ b"an%hes De%"eased &enous '+o, 'a!averin 2A is el!ful Venous 5rom.osis Acute 2MA occlusion o MC due to ru!tured AAA Aoss of collaterals in 2MA and 22A distri.ution 241.Doppler findings in !esenteric isc"e!ia: o SMA H Q2+* 'SV" QF* B#V& 6or Q+0O stenosis o Celiac , Q 200 'SV" Q** B#V& 6or +0O stenosis Normal flow in Celiac is )00cmLsec Normal flow in 2MA %E,)8+ o NoteC Normal flow in celiac is .i!asic H low resitance system 2t does not cange wit fastingLfed state SMA will cange !asicity wit fasting 6asting H tri!asic 'ost !randial H .i 0dro! in !eri!eral resistance1 Also" re!laced R?A may ma:e flow .i!asic ?ence" all measurements in SMA are done in 6AS52NK state Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age )%% Canadian Vascular Surgery Minimum 242.Co!!on *ariations of Co!!on Hepatic Artery: Normal anatomy seen in 80O )0O A?A is off A gastric artery ))O R?A and FO C?A can ta:e off SMA 243.&reat!ent of !esenteric isc"e!ia: o 2ndicationsC Classic / 'ost !randial !ain 6ood fear -eigt loss 2 out of E vessels occludedLstenosed Mimic:ers ruled out 'ancreatitis Cancer 'U# !syciatric o Celiac and SMA orificial stenosis t/C 'taLstent H !oor !atency rates" !oor dura.ility" less sym!tomatic im!rovement 3y!assC Su!raceliacC o Su!raceliac aorta less diseased More diff to e/!ose ten iliac May need to enter cestM o Su!raceliac to C?ALSMA o 3ifurcated #acron Vs Seatle slug 8 mm single #acron to Aongitudinal o!ening of .ase of celiac onto aorta Aong !atc angio!lasty of te celiac origin wit te ood of te graft to te SMA& ?ood starts on aorta and ends on te Celiac& o Retro!ancreatic tunneling to SMA 2liacLinfrarenal aortaC o 3ifurcated o Basier to e/!ose o Ris: of :in:ing o 2nflow may .e more diseased Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 200 Canadian Vascular Surgery Minimum 5ransaortic endarterectomyC o Most difficult o 2f ave simulataneous renal a& revasculari;ation Medial visceral rotation Control su!raceliac aorta 244.Differences .etween acute and c"ronic !esenteric isc"e!ia: o Acute !revious em.olism elsewere no !revious K2 sym!toms clear source of em.olism !atent SMA origin" meniscus" no collaterals s!aring !ro/imal 4e4unum o cronic vasculo!at !revious !ost!randial anginaLweigt loss low flow or intra !la>ue emorrage no em.olism clot at SMA origin" see collaterals entire SMA distri.ution :noc:ed out 245.How to deter!ine intraoperati*e .owel *ia.ility? o ClinicalC visi.le !al!a.le !ulsations in te mesenteric arcade normal colourLa!!earance !eristalsis .leeding from cut of surface o Aa.oratoryC #o!!ler signal on antimesenteric side -oods lam! and fluorescin in4ection Surface o/ymetry 2ntracolonic !? monitoring and 2MA stum! !ressure for large .owel RENOVASCULAR DISEASE 246.Differentiate Reno*ascular Hypertension fro! ot"er causes of H&(? o More common in Caucasians o =ounger age Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 20) Canadian Vascular Surgery Minimum o 5in !ts o Aess fam / o Recent onset o Accelerated course o More severe 0#iastolic Q )0*1 Oter im!ortant cluesC o Onset of a;otemia on ACB2 o ?y!o:alemia wile off diuretics o ?y!ertension resistant to E drug o Unilateral small :idney o A.do .ruit 247.#ec"anis! of renal H&(: o UnilateralC One cli! model Renin driven On stenotic sideC o one sided renin secretion ,Q aldosterone" te oter 0Normal1 side o com!ensates .y natriuresis o :ee!s te volume down y!ovolvemia and y!o!erfusion drives u! renin Unilateral stenosis leads to over!roduction of renin wic H troug Angiotensin 22" drives !ressure u!" remodels CVS" retains Na" and may ave direct to/ic effect on tu.ular elements of :idney& 5is effect is counteracted .y contralateral normal :idney wit natreuresis& o 3ilateralC two cli! model volume e/!ansion" initially" driven .y .Ll secretion of renin,Q aldosteron Bventually aldosterone is su!!ressed New set !oint for e/!anded effective circulating volume is esta.lised CVS undergoes com!ensatory y!ertro!y 3ilateral RAS leads to y!eraldosteronism" y!ervolemia" and ten sustained ada!taion of te CVS to iger !ressures& Renin will .e su!!ressed .ut ?5N !ersists due to y!ervolemia and ada!tive CVS canges !ersist Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 202 Canadian Vascular Surgery Minimum 2t is difficult to distinguis early iscemic ne!ro!aty 0reversi.le1 from cronic !arencimal disease 0not reversi.le1& 2n te end" y!ervolemia" vascular y!ertro!y and vascular reactivity sets in& 248.Captopril nep"rogra!: Can9t use for .ilateral RAS and if Cr is elevated 0a.ove )&2 or )001 Angiotensin 22 H o constricts efferent arterioles" maintaining K6R wen .lood flow is reduced to glomerulus& o -it cronic RAS" K6R .ecome tigtly de!endent on increased !arencimal !aracrine A522& o 2ncrease in ACB2 acitivity dro!s AK22 !roduction K6R dro!s as well& Nuclear !erfusion scan done at .aseline" ten ) after 2*,*0mg ca!toril& -ill see decreased e/cretion of trace wit RAS side com!ared to normal contralateral renal a& #iagnosis is made if 'ea: u!ta:e is delayed Q )) min !ea: of K6R is delayed Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 20E Canadian Vascular Surgery Minimum asymmetry of u!ta:e .etween :idneys cortical retention of radionuclide 249.Renal a@ duplex: o Accessory a& seen in )0O o A.errant 20O 0enter :idney outside of ilum1 2deally" would li:e to interrogate entire renal artery wit G0 degree angle corrected #o!!ler& o 'SV Q )80" RALAortic 'SV ratio Q E&* , Q G0O stenosis o B#V Q )*0 UQ 80O stenosis 'arencimal angle,inde!endent s!ot readings& Allow to measure R2" wave sa!e" A5 Resistive inde/ o 'ea: systolic fre>uency sift H '#6SL'S6S Q *O difference .tw :idneys indicative of Q *0O stenosis R2 Q 80O , igly unli:ely to .enefit from surgery or revasculari;ation o Seen in intrarenal vessel disease o Seen in su.ca!sular collection o Seen in low CO 5arda and !arva waveforms acceleration time Q 0&0+ sec acceleration time inde/ QE mLsec 2 250.Surgical causes of "ypertension: o RAS o Aortic coarctation o 'eocromocytoma o Conn9s o Cusing9s 251.Causes of R- H&(/ R- "ypertension: o RAS o Aterosclerosis o Congenital H .andsLwe.s o 6M# o Bm.olism" leading to !arencimal diseaseC o ?eart o Aortic aterosclerosis o Aortic aneurysm o Renal artery Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 20F Canadian Vascular Surgery Minimum o Renal aneurysm o #issection o Aortic o renal o AVM o 5rauma o -eird < -onderful VasculitisC 5a:ayasu 'AN Neurofi.romatosis Necroti;ing Angiitis 'ost surgeryC 'ost .y!ass stenosis 'ost trans!lant stenosis 252.R- H&( treat!ent and results: 2n treating RV ?5N your o!tions includeC o Medical tera!y o 2nterventionalC
2ndications for interventionC RV ?5N 2scemic ne!ro!aty Acute traumatic occlusion of renal artery 0see trauma1 Concomitant su!re,renal aortic clam!ing re>uiring reconstruction of renal a& 3efore considering revascular;ation" loo: at Renal !erfusion scanM Measure corte/ widt 0cortical atro!y H Q !oor res!onse to revasc1 Renal !erfusion scan 0#MSA .etter tan #5'A1 9( +oo=s a( (ime (o (he .ea= a%(i&i($ 2 measu"es 5e"'usion o' (he =idne$ o Kood study to order to wor: u! failing graft due to anastomotic failure E7%"e(ion 2 measu"es %o"(i%a+ 'un%(ion o Cortical atro!y H .ad !rognostic sign" as is !ole,!ole :idney si;e R 8 cm ;u"gi%a+ "e%ons("u%(ion- Aortorenal .y!ass 5rom.oendarterectomy Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 20* Canadian Vascular Surgery Minimum o 5ransrenal o 5ransaortic S!lancnorenal .y!assC ave to ensure celiac artery !atency o ?e!atorenal H easier" :oceri;e duo" 2# !ortral triad" sort .y!ass to R renal o S!lenorenal H 32K deal" need to rotate viscera" discect .eind !ancreas B/,vivo reconstruction Endo- .TAs(en( 2deal for 6M# 0medial fi.ro!lasia ty!e1 'rimarily for ?5N treatment" not effective for CR6 long term Je5h"e%(om$ H only if :idney is non,functional AN# disease is non,reconstructa.le -yD o B>uivalent .lood !ressure res!onse wit revasculari;ation and ne!rectomy o 2m!roved renal function after revasculari;ation confers a survival advantage& )''e" su"ge"$ (o 5(s ,i(h se&e"e HTJ (ha( is di''i%u+( (o %on("o+ medi%a++$ on mu+(id"ug "egimen8 Role of '5ALstent in management of Renal Artery StenosisC
5ere is no indication to intervene as 3' is o!timally controlled '5A is not dura.le for renal failure& '5A as no effect on survival& Restenosis could .e u! to E+O o less wit stenting& o AS5RAA study is designed to com!aire '5A vs medical tera!y& 'reliminary results , B>uivalentD '5A wor:s .est for non,osteal lesions due to to 6M#& May .e offered for !ts wo are at ig ris: of o!en surgery& Results of renal '5A vs surgeryC cumulative data from Ruterford ?5N ?5N ?5N CR6 CR6 CR6 Cure Sta.ili;ed 6ailed 3etter No cange -orse Surgery" !&)8)E,)F )2O +EO )*O F0O *0O )0O BN#O" !& )8F0 )0O *0O F0O 20O G0O 20O Same cure for ?5N .tw surgery and BN#O .ut E time more failure wit endoM Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 20G Canadian Vascular Surgery Minimum 2nitial 20O vs F0O im!rovement in CR6 .ut tat does not last for BN#O o At * years only 2*O sustain teir renal function +*O get worse OR go on dialysis Com!are tat to **O dialyais free stay for * year for o!en surgery O!en surgery for Renal failureC o 5e worse te failure te .etter te res!onse to revasculari;ation Creatinine level g 2m!rovement in R6C R )&8 g E0O QE&0 g G0O 6or !rognostic info to see if tere is going to .e an im!rovement in R6 !ost surgery" te most im!ortant is te RA5B of renal function decline .efore surgery o #ia.etics may not res!ond to revasculari;ation 253.Indications of conco!itant aortic and renal reconstruction:
58 181L, 180L Asym!tomatic !ts C NO role for prophylati reonstr!tion. Assuming tat due to !rogression of aterosclerosis RV ?5N occurs first followed .y renal failure 2f we were to ta:e )00 asym!tomatic !ts o e/!ect RV ?5N to develo! in FF& -it medical managementC o out of FF" )G 0EGO1 will !rogress to loss of te renal function& 2f tese )G !ts are o!erated u!on" )) 0G+O1 will regain R6" o te rest 0* !ts1 won9t& ;o MK o' 5(s ,i++ be +os( i' no su"ge"$ is o''e"ed8 )00,Q FF,Q)G,Q*M& 2f Surgery was offered at te outset on all )00 !tC ten e/!ect to ave o OR mortatlity of *&*O" o early tecnical failure of 0&*O o late failure in FO H i8e8 a (o(a+ o' 10 5( 6K# ,i++ be ha"med i' su"ge"$ is done 5"o5h$+a%(i%a++$8 Ris: .enefit analysis does not su!!ort !ro!ylactic re!air in asym!tomatic !ts Sym!tomatic !atientsC Unilateral diseaseC o 2f ?5N H if mild" do ca!to!ril" if !ositive H OR o 2f ?5N severe H em!iric OR Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 20+ Canadian Vascular Surgery Minimum 3ilateral diseaseC o 2f RAS Q80O , em!iric OR o 26 RAS G0,80O , cec: ?5N severe H OR 2f mild H cec: CR6 H 2f a;otemic , em!iric OR" if not H medical tera!y Em5i"i% "e5ai"- o for !ts wit ?y!ertension or ?y!ertension AN# CR6 o a causal relationsi! .etween RAS and tese se>uella as not .een esta.lised e7am5+e- G0 yom needs o!en AAA re!air" tigt .ilateral Q 80O stenosis" Cr 200& -ould you offer surgeryD -ould li:e to :now if e is y!ertensive& 2f e is" ten offer surgery o Additionally" 'ts as a;otemia wic strengtens indication for intervention 2f !t as unilateral RAS and ig CR .ut NO ?5N" ten tere is no role for reconstruction& 254.Renal artery aneurys! repair indications: RA aneu %0O e/tra" )0O intrarenal BtiologyC o Aterosclerotic o Most common H medial degenerative !rocess o 6M# o #issection o Vasculitis 0'AN" 3ecet1 o trauma o Sym!tomatic Ru!ture 0calcification not !rotective1 !ain Bm.oli;ation leading to ?5N" CR6 ?ematuria Collecting duct o.struction acute dissection treatening :idney via.ility o any si;e in women of Cild .earing age < !regnant Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 208 Canadian Vascular Surgery Minimum OSABR suggests watcful waiting for last trimester" re!air in te first& o Q E,F cm in asym!tomatic Management o!tionsC Re!air wit inter!osition graft B/,vivo re!air wit autogenous vein reconstruction 'ro/Ldistal ligation wit aortorenalLe!atorenalLs!lenorenal .y!ass Ne!rectomy along wit aneurysm 5ranscateter em.oli;ation of saccular aneurysm or stent 255.Approac" to renal arteries: o Midline or 5ansverse incision Advantage of transverse incision H andle instruments !er!endicular to longitudinal a/is of te .ody o Su!raum.elical o Mid a/il,Qmid clavicular o R renalC R medial rotation of colon and Ioceri;ation of duoL!anc ead #issect middle of R renal a& first 2f start distally , trou.lesome .leeding Retract R renal vein ce!alad o May need to ligate adrenalLsmall .rances 5en dissect osteum o Aigate lum.ar veins o 'us 2VC laterally o A renalC A medial rotationC .etter tan transmesenteric Aigate A gonadal and adrenal vein Retract A renal vein ce!alad o Aorta is dissected for * cm infrarenally o 6luid load and give )2&* g of manitol .efore clam!ing o KSV graft H s!atulate .ranced !ortion and anastamose it to aorta first 5unnel R graft retrocaval" A graft .eind R renal vein 256.x)*i*o reconstruction: indications o -en reconstruction Q F* min o All lesions involving .rances 0RAA" stenosis" AVM" dissection1 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 20% Canadian Vascular Surgery Minimum o 6ailure of !rior reconstruction 257.Indication for repair of renal artery in trau!a: Sta.le !t 2n te setting of la!arotomy for oter reasons 5ime to in4ury more tan G 0if one :idney is damaged1 5ime to in4ury more tan 20 0if SOAB or 3O5? :idneys are damaged1 -y conservative a!!roacD Success of revasc is only E0O 2f successful H )2,*0O cance of y!ertension" if decided to treat concervatively H ave F0O cance of ?5N AAA 258.AAA epide!iology and cause: #efinitionsC Aneurysm if more tan )&* normal diameter Arteriomegaly , Q )&* diameter in long multi!le segments of arterial system wit no discerna.le aneurysm& o 2,G times more common in males o 2,EL)000 !ersonLyears o A.ove G* yoa H *O males" )O females" 2n !ts wit 6? of first degree relativeC o 2*O males" *O females 0i&e& * fold1 o 2n men" AAA .egins at *0 !ea:s at 80 +O of tese is familial o 2n women" .egins at G0 )2O of tese is familial o 2f !t as AAA" tere isM 2*O cance of aving iliac aneu o Common iliac aneurysm )0 times more common tan internal iliac B/!ect growt rate of F mmLyear No ru!tures seen less tan E&8 cm R twice more common tan A Re!air if a.ove E cmD BVAR !referred $VS 2008" F+C)20E,)) )2O cance of aving toracic aneu REO of AAA will ave fem Aneu Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2)0 Canadian Vascular Surgery Minimum 2f see H need to fi/ if o sym!tomatic 0massLAteroem.olism1 o if Q2&* cm if asym!tomatic Conversely" *0O of fem aneu will ave AAA o according to Ruterford 0osler course say %0O1 E0O of fem aneu will ave !o! aneu E,+O AAA will ave !o! Aneu o E0O of !o! aneu will ave AAA 0*0O according to osler1 '& )*E* CauseC 'roteolytic en;ymes 0MM',2" %" tissue ini.itors of MM' , 52M'1 #ecreased elastin in infrarenal aorta #ecreased vasa,vasorum in infrarenal aorta Reflected !ulse waves from aortic .ifurcation 2nflammationLinfection Kenetics 259.Principal !atrix fi.ers in aorta/ w"at c"anges are seen in AAA? o Blastin and collagen o MM' H matri/ metallo!roteases res!onsi.le for degradation o #egradation of elastin is res!onsi.le for growt o Aoss of collagen is res!onsi.le for ru!ture 260.Risk factors for AAA D&C&IO(: 2NCRBASB# R2SI inM o Smo:ing o 6? o Older age o Male gender o ?ig col o CA# o CO'# o 5all statue #BCRBASB# R2SI inM o N a.dominal imaging witin * years o #V5 o #M o 3lac: race Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2)) Canadian Vascular Surgery Minimum o 6emale gender 261.(atural "istory AAA o Rate of e/!ansion for aneurysm .etween F,G cm is )0O !er year o Ru!ture ris: is related to si;e o RF cm 0 o F,*cm 0&*,*O o *,G cm E,)*O o G,+cm )0,20O o +,8 cm 20,F0O o Q8 cm E0,*0O Selection of !atients for surgeryC Ris: of ru!ture Ris: of surgery Overall !t fitness Aife e/!ectancy Mos( 5(s do no( bene'i( '"om "e5ai" un(i+ M8M %m, un+ess i( is ,oman 6M %m# R* cm H follow wit serial US at G monts intervals *,*&* cm H elective re!air in young" low ris: " good life e/!ectancy suc tat eventual re!air is almost certain if *&* cm tresold is reaced 6or iger ris: !ts" consider raising o!timal tresold si;e" e&g& G cm& o See modified Aee criteria Screening reduces mortality of AAA .y *0O& *0O of aneurysm .etween F&0 and *&* cm re>uire fi/ing witin E years 0A#AM" UI1 +*O of aneurysms .etween *&0 and *&* cm re>uired re!airM Note mall aneurysmsC 2F"000 conse>uitive auto!sies over 2E years F+E AAA found ))8 of tese H ru!tured )EO of tese are under * cm 0difficult to !redict si;e on auto!sy1 Ris: of ru!ture for AAA F&G,*&F is a.out 0&*,)O annually& 262.Rele*ant C& findings in pts wit" AAA o Venous anomaly Retroarotic A renal vein #u!licated 2VC Aeft sided 2VC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2)2 Canadian Vascular Surgery Minimum o Renal anomalies ?orsesoe 'elvic :idney o Nec: of aneurysm 'ro/imity to renal a Accessory renal a& o Oter items to considerC 2nflammatoryD 2liac aneurysmD 'resence of Aortoiliac occlusive diseaseD Oter significant non,vascular !atologyC K3 cancer" .owel Ca etc SMALCeliacL2MAL22ALrenal stenosis" arcs of Reolan 263.R1 for AAA rupture Normal rate of growt H 0&F cmLyear 'ROVBN o Aarge si;e o ?5N o CO'# o 6emale gender o smo:ing SUS'BC5B# o 6amilial ineritance" !articularly in females o Bccentric sa!e o ?ig e/!ansion rate o A.sentLminimal trom.us 264.Ruptured AAA !anage!ent: o A.do !ainL.ac: !ain in !t wit :nown AAA o 6aintingLy!otensionLa.do !ulsation o 5ender !ulsatile mass rLo C?6" swollen legs" a.do .ruit" 2VC dye in arterial !ase o Bsta.lis 2V .ut :ee! 3' at te minimal level to allow normal mentation o 2f sta.le" may consider C5 for !lanning BN ROU5B to OR o 2n OR H !re! first" induce wen ready to cut o Su!raceliac clam! if large ematoma at nec: o No e!arin if large ematoma o 5ry to get away wit sortest !rocedure 0i&e& tu.e graft1 o 3ac: .leed iliacs !rior to com!letion Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2)E Canadian Vascular Surgery Minimum o Consider need to leave a.do i!en Wha( de(e"mines 5oo" ou(%ome in "u5(u"eV )& Admission and intrao! S3' R%0 2& 'reo! Cr Q 200 mmol 0Q2&*1 E& 'reo! ?g R)00 F& OR .lood loss Q+ A *& More ten )0 u !R3C transfusion G& OR uLo R 200cc total +& 5em! R%)6 0EE C1 265.Infla!!atory AAA: o Same rate of ru!ture as AAA o Unclear if tis is distinct entity vs !art of te s!ectrum o No role for !rimary management of oter organ involvement i&e& #O not decom!ressLrelease o.structed ureters may stent tem most will settle conservatively after AAA re!air o Role of BVAR is .eing defined o Use 5eflon !edgets if re!air o!en H do retro!eritoneal 266.Indications for retroperitoneal RP repair: o ?ostile a.domen o 2nflammatory AAA o ?orsesoe :idney o Ascitis o 'eritoneal dialysis o o.esity 267.Anato!ic criteria for -AR: o Nec: Q)* mm long" RE0 mm wide" R G0 degrees angulated o Nec: is non,divergent" no calcium" no trom.us o 3ifurcation minimum 2F mm Coo:" 28 mm 5alent if .ifurcated Non,issue for AU2 o R %0 degrees aortoiliac angle o 2liacs at least + mm 268.&ypes of endoleaks: a& !ro/imal" . distal" c troug occluded CA iliac in AU2 Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2)F Canadian Vascular Surgery Minimum sac flow via H o a& single vessel 0not !ossi.le for long1" o . more tan 2 structural failure H A H 4unction" 3 H tear or ` !orosity endotension H sac: e/!ansion wit no endolea: 269.Specific co!plications of -AR )endo*ascular AAA repair Overall" ris: of Ma4or Adverse Bvents after BVAR is u! to E0O& Most of tese can .e managed endovascularly& 6reedom from Ru!ture at % years is a.out %FO 0800 cases from MK?" 3oston1& BARA= o Radiation e/!osure to !t and !ersonnel o contrast allergy o renal failure o Access traumaC !erf" dissect" trom.osis Microem.oli;ation of !la>ue or AAA trom.us o Kraft dis!lacement or mis!lacement Occlusion of RA" 22A" SMA o Bndolea: o 'ostim!lantation syndrome fever .ac:ace malaise o graft lim. com!ression H trom.osis" stenosis" occlusion AA5B o Kraft migration o Bndolea: o Aim. stenosis" :in:" trom.osis o AAA ru!ture 270.1ollow up after -AR@ ndoleak treat!ent: C5 scan at ) mont" ten annually 5e !ur!ose of BVAR is to !revent ru!ture of te aneurysm early identification of endolea:s is intended to el! acieve tis goal& treatment of endolea:s , te most common reason for readmission of !atients after BVAR& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2)* Canadian Vascular Surgery Minimum 20O of !ts e/!erience endolea: o +O at first C5 Most early endolea:s 0+0O1 disa!!ear o )EO later Ris: of ru!ture of ty!e 2ALcom.ined wit 222 is AO- o in BUROS5AR registry 02800 !ts1 is )O !er yearM o FO over E years Still" all ty!e ) sould .e fi/edC o e/tension vs !alma; vs e/ternal .anding vs conversion to o!en 6reedom from aneurismal ru!ture after BVAR" categori;ed .y endolea:s !resence& 5y!e 22C seen in F0O .efore E0 days" te rest later No ris: of ru!ture wit ty!e 22 No general agreement a.out te need for graft related interventions in !ts wit endolea:s Controversy reC most a!!ro!riate ty!e of intervention for ty!e 22& o Coil" glue" la!arasco!icLo!en cli!!ing vs o.servation 5y!e 2 wit sac srin:age o No intervention" continue follow,u! 5y!e 2 wit sac e/!ansion o Seen in )0O of cases o Most will recommend intervention o Sac e/!ansiong migration < distortion of fi/ation sites gty!e 2L222 lea:gincreased ris: of ru!ture 5y!e 2 wit sta.le sac si;e o Controversial o Safe to o.serve according to Silver.erg et alM Sac: enlargement is seen inC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2)G Canadian Vascular Surgery Minimum in 20O of !atients wit ty!e 2L222 endolea: 2n )0O of !atients wit ty!e 22 endolea: 2n *O wit no endolea: 271.Drea!/ -AR E and -AR 9 findings o #RBAM F00 !t" RC5" te first to sow EO ARR in favor of BVAR o BVAR ) H M40 5( in ea%h g"ou5 6it !ts" evar vs o!en )&+O vs F&+O mortality at E0 days EO vs +O mortality at F years Overall mortality same at F years 2GO vs 2%O" NS #isease s!ecific mortality at F years H EO less for BVAR Suality of life im!roved for BVAR for E monts only ConclusionC Continue to e/!lore te issue Not enoug evidence to cange !ractice o BVAR 2 Unfit !ts" evar vs o.servation %O mortality at E0 days in BVAR grou! At F years" Overall mortality is G+O vs G*O" sameM No im!rovement in >uality of life 272. Har*ard #edicare Registry study Registry review" NO5 RC5 2E"000 !ts wo ad BVAR matced to 2E"000 of !ts wo underwent o!en 20O women" )0O ad M2 !reviously 'erio! mortality )&2O vs F&8O o ARR 'o" AL/AN 2 3K o ARR 'o" >8M $oa 2 88MK Com!licationsC BVAR o!en M2 +O %&*O !neumonia %O )+O Renal failure *&*O ))O #ialysis 0&FO 0&*O Acute mesenteric isc )O 2O Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2)+ Canadian Vascular Surgery Minimum All ave significant ! Mortality .enefit !ersisted for a.out E years o ) year for G+,+F yoa o F years for Q8* yoa F year o.servation BVAR o!en ru!ture 2O 0&*O reintervention %O 2O Aa!arotomyLernia com!lications FO )0O Mortality com!arison .etween BVAR vs o!en" ?arvard registry Age g"ou5 endo&as%u+a" o5en Abso+u(e di''e"en%e AAA )&2O F&8O E&GO G+,G% 0&FO 2&*O 2&)O +0,+F 0&8O E&EO 2&*O +*,+% )&EO F&8O E&*O 80,8F )&GO +&2O *&GO Q8* 2&+O ))&2O 8&*O -o goes omeD #irect ome vs rea. outcomesC BVAR vs o!enC age EGAR ).EJ Abso+u(e di''e"en%e AAA AKBS %F&*O 8)&GO )2&GO G+,G% %+&8O %2&GO *&2O +0,+F %G&8O 88&+O 8&)O +*,+% %F&FO 80&FO )FO 80,8F %0&GO G+&+O 22&%O Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2)8 Canadian Vascular Surgery Minimum Q8* 8F&GO *+&)O 2+&*O ConclusionC Aargest o.servational study of o!en vs BVAR BVAR Survival .enefit de!ends on age o te older , te more and longer o Survival .enefit of BVAR disa!!ears wit time 6unctional outcomes of BVAR are .etter o te older" te .etter H after 80 yoa astounding 2*O ARRX BVAR reinterventions were .alanced .y la!arotomy com!lications in o!en grou! More ru!tures wit BVAR 273. Indications for angio in pt wit" AAA: angio for AAA o 5ALsu!rarenal aortic aneurysm o Cronic aortic dissection o ?orsesoe :idney o Sus!ected renovascular or visceral arterial disease o 2lio,fem occlusive disease o Associated !eri!eral aneurysm THORACOABDOMINAL ANEURYSM 274.&"oracoa.do!inal aneurys! F&AG Notes on anatomyC 5in: of a giant slug gradually sliding down ten crawling .ac: u! ?ig ig" ig low" low low" very low" middle No renal involvement in ty!e ) and * 5y!e 2 is te most e/tensive 5y!e F is a .ad version of su!rarenal aneu 0!ro/ suture line a.ove celiac1 Most are degenerative o 5inning of media" destruction of SMC < elastin 20O are familial Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2)% Canadian Vascular Surgery Minimum Syndromes associated 5AAC o Marfan 0MC1 6amilial H +*O New onset H new mutation 2*O o 5urner o Blers,#anlos o 'olycystic Iidney #issection 020O of 5AA are due to A#1 o Conversely" u! to F0O of A# end u! in aneurysm at + years 2nfectionLtrauma 0minority1 o Salmonella" ?&6lu" Sta!" 53" 5re!onema1 'redictors of ru!tureC normal rate of growt H 2 mmLyear o Si;e Q + cm o )cmLyear e/!ansion o ?5N 0diastolic1 o Smo:ing o CO'# o Kender 06QQM1 o Age H u! 2&* folds for every decade 6or Q+0 yoa" *0O ris: of ru!ture witin )&* years Ris: of re!airC o CO'# o Rena+ Dai+u"e 2 F" > 300 638M# 2 5oo" 5"ognosis 'o" "e5ai" o Longe&i($ assessmen( o Mo"(a+i($ o' "e5ai"- 10K in %en(e" o' e7%e++en%e 30K %oun("$ ,ide 'resentationC o 'ressure effect #ys!agia ?orseness Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 220 Canadian Vascular Surgery Minimum SO3 Visceral !ressure Ureteric com!ression o Ru!ture 2ntra!eritoneal 2nto !leural cavity 2nto R' 2nto K2 0duo1 2nto 2VC 2nto ureter o Ateroem.olismC Visceral vessels Aower e/remity 275.Decision !aking in assessing pt wit" &AA: Ri:s of OR o Surgical detail B/tent 'ro/ < distal Visceral involvement Aortic >uality Calcified 5rom.us in 5%,A2 Comor.idities Modified Aee" es!ecially Renal failure Aife e/!ectancy o Ris: of Ru!tureC ?5N Smo:ing CO'# Si;e 9n gene"a+, do no( o5e"a(e on TTA R A %m 6e7%e5( in ($5e 4 2 M (o M8M as in in'"a"ena+ and Ma"'an 5(s# Overall" E0 days mortality is close to )0O&&& 5y!e 22 ad 2%O ris: of s!inal cord iscemia .efore institution of ad4uncts o Aess wit ad4uncts&& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 22) Canadian Vascular Surgery Minimum 276.Strategy for renal protection in &AA: KoalsC reduce renal o/ygen use" reduce direct renal tu.ular in4ury" maintain !erfusion o ?old ne!roto/ins 0ACB2" aminoglycosides1 o #istal aortic !erfusion o Only !rotective wen renal a& do not re>uire reconstruction o i&e& for ty!e ) and *M o Selective visceral !erfusion o 2t #OBS !rotect te liver o Retrograde y!otermic renal venous !erfusion to )* degrees o 3ut :ee! core .ody tem! at E2,EE degrees o ?olds a lot of !romise according to SafiM So far" none of tese tecni>ues ave .een sown to definitively reduce incidence of R6 277.%"y is t"e spinal cord at risk during repair of &AA? S!inal cord .lood su!!ly o one anterior H !rinci!al varies in si;e discontinuous in some !eo!le receives radicular .rances from intercostals or te u!!er lum.ar arteries& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 222 Canadian Vascular Surgery Minimum o largest of tese aortic .rances is called te great radicular artery of Adamc:iewic; or arteria radicularis magna 0ARM1 arises .etween 5% and 5)2 o two !osterior arise ce!alad from .rances of te verte.ral a& run troug te total lengt of te s!ine end in a conus !le/us of lum.osacral .rances& 5e most li:ely cause of !ara!legia after toracoa.dominal aortic aneurysm surgical treatment" eiter tem!orary of !ermanently is te interference wit te Adamc:iewic; artery& AsideC anterior s!inal syndrome H .Ll !aralysis and loss of !ainLtem!erature& 2ntact !ro!rioce!tion 'osteriorC loss of !ro!rioce!tion and vi.ration& 'reservation of touc" !ain and tem!erature 278.Spinal cord protection !et"ods during &A repair: o #istal aortic !erfusion 'assive 0A/,fem" Kott sunt1 Active o A atrial,fem .y!ass o Com!lete cardio!ulmonary .y!ass o 'erio!erative CS6 drain S!inal cord !ressureU MA' H CS6" :ee! CS6 !ressure at R)0 mm ?g :ee! MA' u! drain )0,)* ccL dLc drain on 'O# E o intercostal aa& Reim!lantation 05%,A21 o e/!editious o!eration o oter ?g Q)00 C2 Q2 MA' %0,)00 o ?y!otermia S!inal 0F degrees C1 o 'armacology Nala/one Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 22E Canadian Vascular Surgery Minimum Steroids Magnesium Calcium cannel .loc:ers O/ygen free radical scavengers .ar.iturates asideC #ifferent tecni>ues were develo!ed since te first 5AAA re!air in )%*FC )%809s Crawford9s inclusion tecni>ueC o !reserve !osterior wall of te aneurysm don9t do tis for Marfan o reim!lantation of te celiac" su!erior mesenteric" and renal artery islands of aortic wall into te !rostetic graft& A renal is sewn in as a .y!ass o called te Clam!,and,sew tecni>ue& 7te less clam!ing time" te less te incidence of !ara!legia8 goal was to com!lete all te anastomosis in a.out E0 minutes Se>uential advancing cross,clam!ing also minimi;ed iscemic time to s!inal cord and a.dominal organs& 5em!orary Aortic 3y!assC o a/illo,femoral .y!ass o left atriofemoral .y!ass using a centrifugal !um! witout e!arin&decom!ression of te !ro/imal aorta !erfuse cord in a retrograde fasion distally allows more time to !erform te !rocedure Reim!lantation of 2ntercostal arteriesC o 5e vast ma4ority of surgeons re,im!lant intercostals wen !atent !articularly in te 5%,5)2 area& o Some locali;e te Adamc:iewic; artery !reo!eratively wit C5, Scan or MRA" o some use somatosensory evo:ed !otentials 0 SB's1 or motor,evo:ed !otentials 0 MB's1 monitoring to ascertain wic islands of intercostals or individual arteries to reattac& 2ntercostal arteries can .e reattaced directly to te graft" troug an individual .y!asses or wit te use of an o.li>ue distal aortic transection wit !reservation of te !osterior wall of te aneurysm Cere.ros!inal fluid drainageC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 22F Canadian Vascular Surgery Minimum o 2n intrao!erative !eriod and e/tending for several days after te o!eration o su!!orted .y a Systematic Review of te literature& o Safi et al tecni>ue" a constant !ressure of )0mm?g is maintained& ?y!otermiaC o Selective cooling of te s!inal cordC o 2nfusion of *0 ml of iced saline into te e!idural s!ace for E0 min .efore aortic clam!ing& o tecni>ue was not consistently !roven as effective&
o te goal is to decrease te tem!erature and decrease meta.olism" 5?US
e/tending te !eriod of iscemic tolerance& o y!otermia reduces te loss of A5' stores wit earlier resolution of lactic acidosis& 'rotection of tissue damage from iscemia may also reduce re!erfusion in4ury& -it te use of te eat e/canger" various degrees of y!otermia can .e acieved 0e&g& 28f C" EEf C1& 'armacologic agentsC o Nalo/one during s!inal cord iscemia" steroids and !a!averine& 5ese tera!ies were not !roven effective& 279.,leeding during &AA/ cause: ?y!otermia Coag factor e/austion o Aiver y!o!erfusion o 'ost .leeding o Aong OR time ?ence" warm u!" .e >uic:" !erfuse liver" re!lace coag factors 066'" cryo1" give volume& 280.%"en s"ould we (O& co*er SCA in t"oracic endografting? 'rominentLdominant Verte.ral on te A A2MA graft is !resent Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 22* Canadian Vascular Surgery Minimum B/tensive coverage of te decending torasic aorta is !lannedH i&e& 5%,A) 'rev AAA re!air 0lum.ar and 2MA collaterals are gone1 AORTIC DISSECTION: 281.Aortic Dissection: Acute dissectionC o 5y!e AC all need re!air .y cardiac surgeon& 2f tere is concomitant mesenteric iscemia" 62J MBSBN5BR2C 2SC?BM2A ) st M o 5y!e 3C aggressive !ressure controlLim!ulse control tera!y surgery forC ru!ture e/!anding aneurysm 0i&e& near ru!ture1 .ranc occlusion ig ris: of ru!ture o Marfan o #iam Q * cm o Aong term steroid failure of medical tera!y o 0i&e& ru!tureLe/!ansionL.ranc occlusion1 manifested .y ongoing ?5N" 'A2N Cronic dissection wit aneurismal dilatation H same indications as for AAA AsideC Classification and management of aortic dissections& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 22G Canadian Vascular Surgery Minimum ClassificationC Sandford 0S for sim!le1 H A , ascending" 3 H descending #e3a:ey classification 0# for difficult1 ) origin in ascending" goes at least as far as te arc or furter 2 origin in ascending" limited to ascending E a H origin in descending" limited to descending E . H origin in descending" goes to a.dominal E c H origin in descending" goes !ro/imally to arc 5reatment of ty!e 3C Medical H EC2 U AC3 More in men less tan *0O !resent wit ?5N im!ulse control wit 33Ldilators is mainstay .etter survival rate wit medical tera!y 0istead trial" 2RA# registry1 goals of treatmentC o Sta.ili;e e/tent of dissection o Reduce intimal fla! mo.ility o Relieve dynamic aortic .ranc o.stuction Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 22+ Canadian Vascular Surgery Minimum o #ecrease ris: of ru!ture indications for surgery , only for com!lications goals of surgical treatmentC o 2nduce aortic remodeling troug 6A trom.osis 2ndications o Recurrent !ain o Ra!id aortic e/!ansion o Ru!ture RFO of acute !resentations" 20O during te course of disease o 3ranc Vessel occlusion Mal!erfusion seen in 2*,F0O of acute dissection Most im!ortant source of M<M #ynamic o.struction 80O Static 20O 6alse lumenC A renal a 5rue lumenC R renal" visceral o #iagnosis and management are usually delayed *0,80O mortality if renal iscemia 8+O if mesenteric iscemia mortality for o!en surgery for mal!erfusion Q 20O o ?ence endovascular o!tion is attractive reduced u!front M<M .ut 2NS5BA# trial sowed same results for stent vs medical in acute A# EO medical )0O stent mortality at ) year" ! NON, significant Surgical O!tionsC o O!en Central aortic re!lacement H for ru!ture 0used very rarely1 O!en fenestration for .ranc occlusion 0used rarely1 'rinci!leC o -ide resection of te dissected se!tum B>uali;e flow troug .ot lumena o %,)0 t 2C s!ace toracoa.domianal e/!osure o Se!tectomy may .e e/tended into visceral vessels 2f small aortaL!oor flowLsus!ected osteal o.struction Resect se!tum o 2ns!ectLtac: !eri,osteal intima o 6enestrate to infrarenal level wit 5eflon !leget o Re!lace infrarenal aorta wit distal dou.le,5eflon !leget anastomosis o Bndo Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 228 Canadian Vascular Surgery Minimum Bntry site sealing Bndo fenestration 'ro.lem wit endoC Bndovascular a!!roac only seals endoluminal source of .leeding Aarge vasa vasorum and intercostals may still contri.ute to late ru!tureLgrowt o Surveillance necessary May not !rovide long,term survival .enefit o 3ridge tera!y troug ru!tureLemergency situationD 6#A Kore 5AK trialC a!!lies to toracic aortic re!air %om5+i%a(ion o5en s(en( !ara!legia )FO EO stro:e )0O *O ru!ture 0O 0O reintervention )0O FO Note" Safi results cannot .e re!roduced .y most centers 0i&e& GO s!inal cord iscemia witout ad4uncts and 2O wit1& Results in real world !ractice are -ORSB& ConclusionC o 6or uncom!licated ty!e 3 H medical tera!y o 6or com!licated ty!e 3 H consider e/!editious diagnosis and treatment Ru!ture or com!lications will li:ely re>uire o!en re!air Stent if local e/!ertiseLlogistics availa.le 26 significant comor.idities H consider stent Stent entry !oint and enlarge true lumen if dynamic .ranc o.struction& Consider fenestration if no outflow for 6A Stent individual .rancesLor individual vessel orifice if static o.struction Consider o!en if failed o Carefully follow cronic dissections for future 5AA )FO at F years F0O at + years AORTOILIAC OCCLUSIVE DISEASE !AIOD" 282.Approac" to pt wit" AIOD: 2n A2O# setting" always as: re Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 22% Canadian Vascular Surgery Minimum 3uttoc: !ainLim!otence 3lueL!ainful toes 2CLR'Lulcer o Claud distance Management of R6 2f !t as AAA in addition to A2O#" ten addM AAA stuffM o B!i 0race" gender" age1 o Sym!toms 0a.do" .ac: !ain" distal ateroem.olism1 o ?ig !ro.a.ility ris: factors H smo:ing" li!ids" CA#" 6? o Aow !ro.a.ility ris: factors H #M" #V5" N a.do imaging o Ris: 6actor for re!airC M2" CVA" CR6" CO'#" ?5N" level of activity" longevity assessment 283.Indication for nd to nd *s nd to Side for A,1: o Bnd,to,Bnd A36 .y!ass configuration #o tis wen B2A o!en and you can re!erfuse internal iliacs 3etter ?# configuration 0teoretical1 3etter tissue coverage 2ndicated for aneurismal aorticLiliac disease Basier clam! !lacement o Bnd,to,Side A36 .y!ass configurationC -en !reservation flow is re>uired in te following systemsC 2MA flow o colon is !reserved iliac system flow o occluded B2A o if .y!ass occludes" !t is .ac: to original state" wit residual iliac system function" allowing at least AIA to .e done accessory renal a& flow and orsesoe :idney median sacral and lum.ar a& flow o s!inal cord !reservation Bnd to side teoretically as more ris: of aterem.olic com!lications and less cances of im!otence& Ouflow management for A36C 2f !rofunda is smallLdiseased AN# !t as distal ulcer" add distal .y!ass 'rofunda,!o!liteal collateral inde/ 0''C21 o 2f Q 0&* H !rofundo!lasty alone will not im!rove s/s Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2E0 Canadian Vascular Surgery Minimum o 2f R0&2 H !rofundo!lasty alone is ade>uate 3est indications for !rofundo!lastyC o Rest !ain and minimal tissue loss o No #M o 'atent distal !o! and outflow wit ''C2 R 0&2 'ossi.le configuration of a/femC 'atency de!ends on indication& 'atency of A36C %0O at * years" +0O at )0 years" EO !erio! mortality A/illo,.i,fem !atencyC +0O at * years A/illo,uni,femC *0O at * years 284.Indication for Axillo).i)fe!oral 7raft: o A2O# in !ts wit CR252AA lim. iscemia not suita.le for A36C 'oor surgicalLmedical ris: Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2E) Canadian Vascular Surgery Minimum ?ostile a.domen o 5o revasculari;e lower e/tremities following removal of an infected graft Aortic graft One lim. of A36 6em,fem graft o 5reating AB critical lim. iscemia following aortic ty!e 3 dissection Com!licationsC )& U!!er lim. iscemia a& Steal .& 5rom.osis wit U!!er B/tremity em.oli;ation c& Anastomotic !seudoaneurysm d& Arterial distortion causing :in:ingLtrom.osis 2& 3racial !le/us in4ury Note" if anastomosis is made to ) st !ortion of a/il artery" anastomotic disru!tion wit sudden arm a.duction is less li:ely& ?emodynamic results of a/,fem MA= NO5 significantly im!rove claudication distance& 5raditionally a/illo,3i,fem are considered to ave .etter !atency tan uni& o ?owever" .est a/fem !atencies were o.tained for uni configuration o Ruterford9s com!anion states tat may .e !atencies are e>uivalent& 285.&ypes of endarterecto!y@ Discuss aortic endarterecto!y o Controlled arterial in4ury tat eals .y intimal re,growt -y BA is !ossi.leD o Cleavage !lane and end!oint is smootC #isease is limited to initima and inner media #isease is segmental o Residual adventitiaLouter media resists dilation Fon("aindi%a(ions (o enda"(e"e%(om$- Aneursmal disease 5a:ayasu arteritis Radiation arteritis Medial calcificationL5ransmural calcification o Multi!le adventitial defects !ost !rocedure 5wo ty!es of aterosclerotic involvementC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2E2 Canadian Vascular Surgery Minimum o 5y!e )C mCfU2C)" younger" aorta" C2A s!are B2A" C6A" outflow o ty!e 2C mCfU*C) older ty!e ) !lus outflow involvement" Aterosclerosis occurs atC o Origin of aortic .rances o Sites of arterial fi/ation o Sites of tur.ulence 5y!es of BAC o )5en o ;emi/%+osed 6"emo(e# 5wo longitudinal arteriotomies at te end and .eginning of te vessel" develo! distal !oint first" ten go !ro/imal& o E7("a%(ion EA -it emostat" develo! !lane ten !ull out !la>ue Antegrade H for aorticL.ranc vessels distal e/tent of !la>ue is 2#9d e/ternally .y !al!ation Aterosclerosis is orificial and smootly ta!ers in te distal vessel Retrograde H for C6ALB2A !ro/imal end!oint is se!arated .y crusing te artery distal end!oint is controlled wit tal:ing suture o E&e"sion H 5ransect artery Bvert o ;e+e%(i&e 2 don9t understand tis one Keneral guidelines for aortic BAC o 32AA5BRAA BA to iliac .ifurcation for ty!e )" and to C6A for ty!e 2 o Bntire media removal ,Q leads to 2,* mm dilatation of te artery May .e res!onsi.le for dura.ility of re!air o Uno.structed outflow to !rofunda Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2EE Canadian Vascular Surgery Minimum 286.Causes of A- co!!unications in*ol*ing aorta and its5 .ranc"es: o Congenital H Vascular malformations o Ac>uired Ru5(u"e o' degene"a(i&e AAA 6M);T F)MM)J# trauma 0low velocity !enetration1 iatrogenic o renal 3/" o s!ine OR H aortaL2VCLiliac damage o mass ligation of s!lenicLrenal !edicle erosion o due to se!sisLaortitis o tumor 0renal Ca" mesencimal tumor .tw AoL2VC1 287.Potential p"ysiologic and anato!ic conse2uences of a large A-1: o 5rauma to te endotelium o ?emodynamic conse>uencesC #ro! in total !eri!eral resistance 2ncreased central venous !ressure #ro! in mean arterial !ressure 2ncreased eart rate and stro:e volume H increased cardiac out!ut 2ncreased .lood volume Kradually increased AVB#' and volume Cardiac failure 288.Aortoca*al fistula: o Commonest cause H ru!tured AAA o Also see arto,renal vein -on9t see infrarenal 2VC contrast No leg edema ?ematuria H +2O" flan: !ain o Clinical features AcuteC 3ruitLtrill Q 2LE AAALmass C?6 Q )LF #ecreased distal !ulses Swollen lower e/tremity" venous ?5N Q )LE ?ematuria Q)LF Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2EF Canadian Vascular Surgery Minimum CronicC RARB AB swelling venous trom.osis !erinealLemorroidal varices ematuria a.do .ruit ig out!ut C?6 'eri!eral circulation steal Role of BVARD 2n clearly decom!ensated C?6 !t" ig ris: for o!en" as a tem!ori;ing strategy may consider BVARM COMPLICATIONS 289.Cardiac and Respiratory Co!plications of *ascular surgery: M2 6atal M2 Aortic surgery 2&2O )&FO 2nfrainguinal .y!ass FO )&8O Carotid endarterectomy )O 0&FO i&e& M2 for aorta 2O" .y!ass FO" CBA )O&&& ?alf of tese is fatalMMyocardial iscemia may .e as common as 20,F0O&&& Role of screeningC undefinedM o CA# is !revalent" .ut rates of M2 are fairly low 0see ta.le a.ove1 o Aterosclerosis does not occur wit most ?# significant stenosis Cardiac screening detect !rimarly ?# sig stenosis o Most autors state ris: stratification is im!recise at .est o Aong term .enefits of CA# revasculari;ation 0if it is !erformed1 may not a!!ly for !ts wit 'V# o Revasculari;ation BVBN for emodynamically significant lesions may not .e .etter tan aggressive medical management CA'R2 0CA3K1 and COURAKB 0'C21 trials 5ere are no validated invasive or non,invasive metods to 2# !alues tat are vulnera.le to disru!tion ?ence !reo! o!timi;ation sould aim at !la>ue sta.ili;ation 2t is agreed tere is role for S5A52NS in reduction of CV mortality o $u!iter trial Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2E* Canadian Vascular Surgery Minimum 3eta 3loc:ers are useful as well o Caution" as tey may .e armful in some !ts 0'O2SB study1 -ell done negative !rovocative test ave ig N'V o 'ositive test" owever" does not ave ig ''V Res5"i"a(o"$- Nosocomial !neumonia H leading cause of nosocomial infectious deat o 't may develo! inanition !neumonitis #e.ilitated" nutritionally de!leted" can9t clear secretions Atelectasis ,Q !neumonia Ris: 6actors H smo:ing" CO'#" o.esity" UR52" !oor ealt Suit smo:ing at least ) mont aead Routine CJR !reo! useless H o )F"000 !ts reviewed ,Q in )F0 CJR a.normal" o 2n only )F !t a.normal findings caused cange in management Acute Res!riratory failureC y!o/ic" y!erca!nic" .ot 'revention of !ost o! !ro.lemsC o 'revent atelectasis o Minimi;e artificial ventilation o Strict glucose control , SUBS52ONB# in recent reviewsM 290.Isc"e!ic neuropat"y: o Aarge nerve H due to trom.osis" em.olism" in4ury o Small nerve H 'AN" Reumatoid vasculitis" Curg,Strauss" -egener" #M o Some say muscle is more susce!ti.le to iscemia tan nerve o Acute iscemia H if more tan 2F denervation H a/onal degeneration o' bo(h m$e+ina(ed and non,myeliated nerves o Cronic iscemia H mos(+$ m$e+ina(ed n8 affected H de and re,myelination" edema& o 5em!oral and functional effect on nerves in umans in not well defined& o Sensory deficits" no #5R seen in *0O of !ts wit 'V# o B/tent !ro!ortional to severity o Stoc:ing and glove distri.ution" distal muscle wastingLwea:ness 0foot ,Q!ro/imal1 o ## H uremia" #M" drug" alcoolism& 3U5 in tese H distri.ution is S=MMB5R2CAA" in iscemia H it is limited to most 'V# affected lim. #iagnosisC 2f an:le !ressure Q*0mm" toe !ressure QE0 H diagnosis is unli:ely Blectro!ysiologic studies Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2EG Canadian Vascular Surgery Minimum 5reatment H o re!erfuse" o may e/!ect slow regeneration of nerve fi.ers and relief of sym!toms 9s%hemi% mononeu"o5a(h$- due (o +a"ge &esse+ o%%+usion H trom.osisLem.olusL'A# o 'eroneal o 5i.ial o 6emoral o Aum.osacral !le/usC Motor and sensory More tan one dermatome" several nerves Arefle/ic flaccid lim. #d H !oor recovery in teseM s!inal o S!astic" y!errefle/ive" e/tensor !lantar res!onse" dissociated sensory loss Cauda e>uine 9s%hemi% monome+i% neu"o5a(h$ ,i(h &as%u+a" a%%ess su"ge"$C o Ma4ority are dia.etics o after antecu.ital fossa access ma4or watersed area for vasa nervorum for all tree nerves o sym!toms witin minutesLours after access o .ounding radial !ulse o t/C ligate fistula 291.Co!plications of aortic surgery: o ?emorrage o #eat o Ureter in4ury o 2scemia Myocardial Colon Renal Aim. cere.ral s!inal o 2nfectionC 'neumonia wound graft Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2E+ Canadian Vascular Surgery Minimum o -ound related Nerve in4ury Non,ealing SeromaLlym!ocele o 2m!otenceLretrograde ed4aculation o RecurrenceC Kraft dilatation 0:nitted1 'seudoaneurysm 292.Strategy to !ini!i>e renal da!age during aortic cla!ping? o Manitol H )2&* H 2* g .efore clam!ing 2ncrease urine flow volume #ecrease effects of cortical !erfusion reduction 6ree radical scavenger o 6luid load .efore clam!ing o Iee! warm iscemia under F0 min o #istal aortic !erfusion May reduce s!inal iscemia Bffect on renal failure is less clear cut wit octo!us devices o -or:s for ty!e ) and ty!e * 5AAA" wen you don9t need to reconstruct renals o Cold !erfusion wit *00 cc F degrees NS -en antici!ating Q F* min clam! time Bffects seen wit )0 degrees tem! lowering o Avoid ateroemo.lism Un!roven H do!amine" fenolda!am 293.Clinical c"aracteristics/ risk and diagnosis of isc"e!ic colitis: 0&*,)0O" overall 2 O o 2f loo:ed for aggressively" will find out in GO of elective cases MecanismC o 5rom.osis of intestinal arcaded due to y!otension Unrecogni;ed y!ovolemia !erio! o Bm.olisation of aneurismal contents o 5raction in4ury o 2na!!or!tiate 2MA ligation Not from witin of aneu Unrecogni;ed significance of 2MA wit celiacLSMA stenosis o Use of !ressors Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2E8 Canadian Vascular Surgery Minimum i&e& 4ust reim!lanting 2MA is NO5 going to solve all te !ro.lemsM Barly !ost o! 02F,F8 1 H .loodyL.row diarrea in )LE of !ts A.do !ainLdistentionLfeverLoliguriaLtrom.ocyto!eniaLleu:ocytosis o #sC clinical !resentation !lus fle/ sig ?ig inde/ of sus!icion 2f sus!ect H sco!e" if more tan mucosa H ?artmann& o R6 !redis!osing to colon iscemia 5ecni>ueC 2m!ro!er 2MA ligation H too distal o 'articularly if meandering a& is !reserved Aoss of internal iliacs o Bm.oli;ation during mani!ulation Retractor in4ury o 5o collaterals o 5o colon O!erative !rocedureC Ru!tured aneurysm 2ncreased J,clam! time 'erio! y!otensionLy!o!erfusion 'atientC Old age Comor.iditiesC o 'revious colectomyLloss of collaterals o 'rev rads o SMALceliac artery disease 'ost o! Renal failure increases ris: of deat E fold 0to )*O1 Aung and eart !ro.lems increase ris: of deat 2 fold 0to )0O1 294.Colon isc"e!ia a*oidance after AAA repair: o Assess 2MA .ac:.leeding H re,im!lant if none or R F0 mm ?g .ac:!ressure Aigate 2MA at orifice ,Q !reserve arc of Riolan cec: wit tonometric colonic mucosa !?C sould .e Q G&8G o 'reserve internal iliacsC Avoid em.olus" don9t ligate o 'reserver !rofunda collaterals o Avoid mecanical mesentery in4ury H e&g&wit retraction o 3etter anestesiaC no anemiaLy!otensionLy!otermia o 3etter tecni>ueC minimal cross clam! time Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2E% Canadian Vascular Surgery Minimum 295.How to pre*ent sexual disfuntion wit" aortic surgery: o #OCUMBN5 'RBO' o R sided dissection of aortoiliac segment o Minimal division of longitudinal !eriartic tissues to te left of te infrarenal aorta o #on9t dissect at te .ase of 2MA o #on9t cut tissues over A C2A o Maintain internal iliacs o Aigate 2MA from witin o Use of retro!eritoneal a!!roac may .e .eneficial Aside" if done wit !recautions" aortoiliac reconstruction 0for A2O#1 may restore !otency in 2*O of !ts& ?owever" if no !recautions are ta:en" incidence of im!otence is close to )00O even among tose tat were !otent& 296.How to i!pro*e pel*ic circulation: Correct inflow H aorticLiliac disease 2m!rove internal iliac Angio!lasty Bndarterectomy 3y!ass su!!ort collateralsC o 2MA reim!lant o 'rofundo!lasty Cec: for !atency of arc or Riolan o 2MA reim!lantaion if !oor collaterals 297.Incidence of co!plications wit" different type of access: o A/illary H *,)*O o 5ranslum.ar H *,)*O o 6emoral H ),)0O 298.Pseudoaneurys! for!ation: causes o no !revious surgery infection due to 2V drug use trauma !ercutaneous intervention H 3= 6AR te most common cause of 'A overallM o !rev surgery" i&e& anastomotic , 2 nd most common +0O degenerative" 2*O infection" * O suture .rea: Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2F0 Canadian Vascular Surgery Minimum 2n general" causes areM& disease related o increased outflow resistance due to AsC !rogression arterial wall wea:ness related o !rogression of AsC o infection o aggressive Bndarterectomy o disru!tion of vasa,vasorum !rostetic graft related o com!liance mismatc o graft dilatation and deterioration anastomosis related o tension due to !osition 0groinLfle/1 o tension due to graft sortness o uneven tension at anastomosis sort graft native artery elongation o suture tear o so U relating to te artery" graft" suture line" infection" !ysical stress" tec errors&& o wen to fi/D Aortic H at F cm 2liac H at E&* cm C6A H at 2&* cm wen sym!tomatic #uring re!air" loo: for te sign of infectionM if infected" see infected graft notes& 299.Post Angio pseudoaneurys!: w"y? o 2nterventional rater ten diagnostic !rocedure o Multi!le cateter e/cange o 5ecnical errorsLine/!erience o 'eri,interventional Multi!le 0e&g& loveno/" !lavi/" warfarin1 anticoagulation o 6emale gender o Q G0 yoa o Aac: of closure device o 'oor selection of access 300.Intraartearial drug in<ection + !ec"anis! of in<ury 3 tx Me%hanisms- o Vessel o.struction wit !articles o #irect endotelial damage wit trom.osis H venous and arterial Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2F) Canadian Vascular Surgery Minimum o ?y!ersensitivity vasculitis o Vasos!asm F+ini%a+ mani'es(a(ions- )& 5raumatic com!licationsC a& AV6 .& !seudoaneurysm 2& 2nfectious com!licationsC a& 2nfected !seudoaneurysm or arteritis .& Mycotic !ulmonary aneurymsC dys!nea" cyanosis" emo!tysis c& endocarditis E& 5rom.otic com!lications leading to iscemiaC a& 2n situ trom.osis at in4ection site .& distal em.oli;ation ,Q iscemia F& 'armacologic effects of te drugsC a& NOM2LM2 wit Cocaine 5era!yC Angiogram to 2# local arterial in4ury )& intimal fla!" 2& AV6" E& !seudoaneurysm" F& trom.osis" *& distal vasos!asm 'armacologic tera!yC )& Vasodilators 0intra,arterial !a!averin" tola;oline 02*,*0 mg1 iv severe vasos!asm 2& Anticoagulants H e!arin" de/tran F0 2f infected !seudoaneurysm H treat as infected graft& 301.%"at increases contrast nep"ropat"y? o Advanced age o 're,e/isting CR6 o ?y!ovolemia o ?y!erosmolar agents o #M o Aarge volume of contrast o Re!eat doses of contrast o Co,ingested ne!roto/in ACB2 ASA Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2F2 Canadian Vascular Surgery Minimum aminoglycosides o Multi!le myeloma o ?eavy !roteinuria o ?ig osmolarity agents Note" non,inonic agents ave similar incidence of adverse side effects as ionic&& 302.Ad*antages of low os!olarity contrast to co!pared to "ig"? o Reduces ris: of severe allergic reactions .y 80O o Reduces !ost,venogra!y !le.itis 0less endo in4ury1 o Aess ne!roto/ic 303.7adopentate Di!eglu!ine aka CO 9? Aow ris: of renal disfunction" .ut !oor resolution& Can cause mesenteric iscemia wit gas em.olism& 304.Co!plications of .lood transfusion: o fatal A3O incom!ati.ility )C million o non,fatal A3O incom!ati.ility )C2*0"000 o fe.rile reaction )C)00 o transfusion related lung in4ury 0rare1 o KV?# in immuno su!!ressed o 2nfectionsC viral ?e! 3" C" ?2V" ?5AV .acterial contamination 0!latelets1 Cagas9 disease 305.Difference .etween sero!a and ly!p"ocele? o Aym!ocele as feeding lym! cannel& -en e/cising" need to ligate it& Surgery is indicated for enlarging AC or ones close to te !rostetic graft 0ris: of infection form ad4acent AN1& 'rior to tis" legs u!" com!ression" !revention of infection o Com!lications of cronic lym! lea:C Malnutrtition Aym!ocyto!enia Anemia 2nfection of underlying graft o 2f cose to investigate H * ml of isosulfan .lue .etween toes" o for mesenteric lym!lea:s H F !reo! 2F o; of wi!!ing cream via NK& o 'ercutaneous treatmentC talc" alcool" .leomycin" fi.rin H effective" coming into foreground Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2FE Canadian Vascular Surgery Minimum INFECTED GRAFT 306.(ati*e *ascular *essel infection:
MTF)T9F AJEHRT;M M9FR)<9AL ARTER9T9; 9JDEFT9)J )D EO9;T9JI AJEHRT;M .);T/TRAHMAT9F 9JDEFTED DAL;E AJEHRT;M Btiology Bndocarditis 3acteremia 3acteremia Narcotic addiction" 5rauma Age E0,*0 Q*0 Q*0 RE0 2ncidence Rare Common Unusual Very common Aocation Aorta Aterosclerotic 2nfrarenal 6emoral Visceral Aortoiliac Aorta Carotid 2ntracranial 2ntimal defects 'eri!eral Micro.iology Kram,!ositive cocci Salmonella Staphylococcus Staphylococcus aureus Oters Oters 'olymicro.ial Mortality 2*O +*O %0O *O 'ost traumatic infected false aneurysm H MC Micro.ial arteritis wit aneurysm , common 2nfected !re,e/isting aneurysm , unusual Mycotic aneu 0!reanti.iotic Q%0O" now R)0O1 RARB Does no( in%+ude- in'e%(ion '"om %on(iguous sou"%e ao"(o/en(e"i% 'is(u+a &as%u+a" s$n(he(i% g"a'( in'e%(ion 18 M$%o(i%- mo"(a+i($ 3MK #ue to endocarditis E0,*0 yoa AocationC o 6emoral 8%O o U!!er e/t )EO o aorta )2O o Cranial FO o SMA o -ere H site of .ifurcations" AV6" coarctations& 3ugsC Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2FF Canadian Vascular Surgery Minimum if no 2V#U H Stre! Viridance 22O" SA 20O 2V#U H SA EGO" 's& Au )GO 2. Mi%"obia+ a"(e"i(is ,i(h aneu- mo"(a+i($ LMK *0 yoa #ue to .acteremia More common tan mycotic At te site of Aterosclerosis Most commonly aorta 0EC) com!ared to !eri!eral sites1 LLK o' a++ in'e%(ed ao"(oi+ia% aneu"$sm: MC B&Coli" ;a+mone++a 2 5"edis5osi(ion (o Ao"(a" SA Also" A2#S" CR6Lemodyalysis !ts are susce!ti.le Q8 9n'e%(ed 5"e/e7is(ing aneu- N0K mo"(a+i($ )*O of AAA grow stuff H un:nown significance o E8O ru!tured o )EO sym!tomatic o %O elective 3ugsC o Sta! H F)O , St& B!i is most common 48 .os( ("auma(i% in'e%(ed- M K mo"(a+i($ Most common" lowest mortality 2V drug use 'ost !ercutaneous !rocedure H Ris: 6actorsC o Aong !rocedure o Re!eat cat o #ifficult access o Arterial seat in Q2F o C?6 o Use of angioseal Most Common microorganism H Sta! Aureus& o 6ungal RARB H in #M and immunosu!!ressed& Ruterford9s com!anion states tat unless !urulence and gross uncontrolled infection" always try to revasculari;e wit autologous in situ re!air AN# muscle fla! 0Sartorius1 'resentationC difficult to detect& o 6ever of un:nown origin o 'ositive .lood culture o Brosion of lum.ar verte.rae o 6emale se/ o 'resence of uncalcified aneurysms o 6irst !resentation of an aneurysm after .acterial se!sis Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2F* Canadian Vascular Surgery Minimum 2f see aortic infection H li:ely micro.ial arteritis leading to aneurysm 2f see femoral infection H li:ely infected !seudoaneurysm" second !ossi.ility , mycotic aneurysm Aa.C Negative .lood cultures" intrao!erative Kram stain o ARB NO5 sensitive enoug to e/clude ds o 2n ru!tured AAAC 3lood culture is !ositive in G%O " Kram stain H in *0O o only ))O Kram stain is !ositive in non,ru!tured AAA Bven in aneurysm wall culture was found to .e !ositive in only %2OM o !&)*88 #SA a!!earanceC o saccualr aneu in normal vessel" o multilo.ulated aneu" o eccentric aneu wit narrow nec: Aum.ar osteomyelitis 2ndium ,))) la.eled -3C el!ful for !rostetic graft infection" NO5 infected aneuM 9n%on("o&e"(ib+e 5"in%i5+es o' ("ea(men(- 18 Fon("o+ hemo""hage 38 Fon'i"m ds- g"am, %u+(u"e 'o" ba%(e"ia'ungiT< Q8 )5e"a(i&e %on("o+ o' se5sis- "ese%(, deb"ide, ab7 i""iga(ion, d"ain 48 .os( o5 ,ound %a"e- d"essing %hange, "e5ea( deb"idemen(s M8 Long (e"m ab7 6. Fonside" "e%ons("u%(ion (h"ough non/in'e%(ed 'ie+d- THE )JLT TEJEJT ).EJ T) CON5ROVBRS=M 307.C& findings for infected prost"etic graft: o 6luid around graft o Kas around graft o 'seudoaneurysm o Soft tissue stranding o Ad4acent verte.ral osteomyelitis o ?ydrone!rosis o Retro!eritoneal a.scess 308.Risk 1actors predisposing to graft infection: o 3acterial contamination of te graft 'erio!erative contamination ?ematogenous s!read from remote source Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2FG Canadian Vascular Surgery Minimum Brosion of graft into KULK2 tract Contiguous !rocess o Ris: factors for contaminationC 'rocedure relatedC o Bmergency surgery o Remote infection o 'rolonged !reo!L!ost o! stay o O!erative !articulars Reo!erative !rocedure Simultaneous K2 !rocedure CrusLRoug tissue andling ematomas Contact .etween s:in and graft o 'ost o! wound infection Altered ost defenseC o Advanced age o 6emale gender o As!irin use 0ematoma1 o Malnutrition o Aeuco!enia o Malignancy o Steroids o Cemo o #M o CR6 o Autoimmune disease 309.Pre*ention of graft infection: o Minimi;e !reo! stay 0to reduce coloni;ation .y resistant flora1 o 5reat remote infection !rior to surgery o Antise!tic !reo! sower 0Cocrane" 20081 o 2mmediate !reo! saving 0Cocrane" 20081 o 'ro!ylactic a./ !reo! o Meticulous sterile surgical tecni>ue Autogenous tissues for .y!ass or endarterectomy Kentle tissue andling" no crus 2odine im!regnated dra!es to limit contact .tw s:in < graft Meticulous emostasis H no ematomasLlym!lea:s Meticulous s:in closure Rifam!in .onded graft 0Cocrane" 20081 Close suction drain 0Cocrane" 20081 Avoid simultaneous K2 !rocedures o Barly recognitionLaggressive treatment of wound infections Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2F+ Canadian Vascular Surgery Minimum o Su!!ort nutrition 310.In*estigation of pt wit" draining R groin wound post A,1 o C3C" BSR" CR' se!sis" inflmmatory state o 3UNLCR" lytes" o: for contrast" need for fluid resusc o 3lood culture" wound culture to 2# microorganism o Kroin USLdu!le/ to see if graft !atent" !seudoaneurysm o C5A a.doL#SA and runoff fluidLgas around graft vascular reconstructive o!tions o 2ndium la.eled -3C scan indirect evidence of infection 311.Infected A,1 graft: Draining sinus in groin post A,1: approac" + o Concerned wit graft infection o Review old OR notes and indications o Review current status of 'V# and need for revasc o Culture .lood and site o Confirm !atency of graft 0dysfunctional graft1 o 2mage H USLC5Langio H i&e& esta.lis te !resence ofM 2nvolvement of anastomosis 'seudoaneurysm e/tent of involvement undrained fluid collectionLa.scess reconstructive !otential o 5reatmentC Bradicate infection Anti.ioticsC o 3road s!ectrum anti.iotics to start wit o Narrow to culture s!ecific a./ wen !atogen is :nown o Continue a./ long term Control source of infectionC o Remove infected graft o #e.ride to ealty tissue o 6la! tissue coverageLdrainLleave o!en Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2F8 Canadian Vascular Surgery Minimum Reconstruction of distal circulation Aimited to groin onlyD Can !rofundaLS6A .ifurcation .e reconstructedD Can graft .e !reservedD Can we consider insitu reconstructionD 2f infection is limited to groin" main .ody may .e !reserved& Circulation may .e reconstructedC via o.turator .y!ass to S6AL!o! OR fem,fem 0medial tunneling1 o if only one lim. is involved and main .ody is o:M Via A/,S6AL!rofundaL!o! tunneling laterally in te area away from te site of infection 5oraco,S6AL!rofundaL!o! -eird<wonderful H carotid !o!liteal .y!ass 2f infection reaces main .ody .ifurcation" an entire graft must come out& 6irst" revasculari;e wit A/,distal fem" ten remove a.dominal !ortion of te graft" de.ride aorta" get anterior s!inal ligament and omental !edicle to .olster aortic stum!& 6inally" remove groin lim.s and oversew native vessels& 312.Classification of graft infection: i&e& 3untC '0 H cavitary graft infection" AAA and A36 ') H e/tra,anatomic '2 H infection of fem !ortion of A36 or cervical of aortoLcarotid Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2F% Canadian Vascular Surgery Minimum 'E H !atc angio!lasty infection KB erosion KB fistula Aortic stum! 313.C& findings of aortoenteric fistula: o 'eriaortic gas or fluid o 'ro/imal !seudoaneurysm formation o 3owel wall tic:ening o Retro!eritoneal stranding o 'lane .etween duodenum and aorta o.literated o 2V contrast seen in .owel Note" tat .arium enema or .arium K2 contrast is contraindicated in AB6 H will o.scure !icture and may cause retro!eritoneal s!illageLinfectionLse!sis& 314.Selection of pts for infected graft preser*ation: o Not #acron o No anastomotic involvement o No se!sis o No !seudamonas NoteC #acron may still .e !reserved .ut less cance of success com!ared to '56B ?owC KeneralC o!timi;e eart" lungs" :idney" nutrition" wor: out revasculari;ation !otential" ma! veins 'retreat wit E days of .road s!ectrum iv a./ #e.ride" irrigate in OR Sterili;e woundC o VancLgent .eads canged every + days o )O iodine dressing 52# Continue culture s!ecific a./ Sartorius muscle fla! coverage Aong term !o anti.iotics On e/am" .e careful wit !resenting !reservation of graft as a first coice" list it as one of te o!tions only& 315.Selection of infected graft for insitu replace!ent: o No se!sis No !ositive .lood and tissue cultures Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2*0 Canadian Vascular Surgery Minimum 3iofilm culture !ositive for Sta! B!i o No graft,enteric, fistula ?owC 2v a./ .road range Sterili;e field o #e.ride o 2rrigate o VancLgent .eads > + days o )O iodine saline dressing Confirm sterili;ation on culture 2n situ '56B, rifam!in soa:ed graft vs fem,fem o Kentamicin im!regnated trom.in glue on anastomosis Sartorius muscle fla! for groin G monts iv a./ ten E monts !o anti.iotics On e/am" .e careful wit !resenting insitu re!lacement of infected graft as a first coice" list it as one of te o!tions only& 316. Results of aortic graft infection treat!ent: Staged 0a/,fem first" ten in 2 days e/cision of graft1 is .est #on9t use !ledgets on aortic stum! H infection nidus 2f a/,fem got infected" ten consider need for revascM o if iscemic" ten may do toracic,fem .y!ass& o 2f see mon!asic signal or F0 mm ?g at an:le" may consider to forgo revasculari;ation Mortality Am!utation Re,infection Survival Q year B/,situ .y!ass < e/cision 20O )*O )0O 80O 2n,situ wit vein )0O *O )O 80O Rifam!in '56B )0O *O )*O 8*O Advantages of in,inisitu vs e/,situC Less 5e"io5 mo"(a+i($ 610K &s 30K# Less am5u(a(ions 6MK &s 1MK# ;imi+a" su"&i&a+ o&e"a++ 317. Aorto)enteric fistula: 'rimary o Aess common overall o #egenerative sterile AAA e/!ansion most common in tis category Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2*) Canadian Vascular Surgery Minimum o #uodenal Ulcer 0second MC1 o Cancer" 63 Secondary o 2nfection at suture line H leads to !seudoaneurysm" e/!ansion" !ressure on te duodenum o 2nfection li:ely latent H s:in flora tat gets activated wit di!s in immunoco!metence 0!& %0F1 o 'ulsatile !ressure o #uodenum H in4ury during 5ransa.dominal mo.ili;ation 2nitial fistulae were at .ody of te grafts wen omografts were used ManifestationC o K2 .leed" se!sis" a.do !ain H rare K2 .leed H seen in 2)O of all AAA re!airs" only 0&FO of all tese .leeds will ave AB6 o 6everLmalaise o Se!tic em.oli Common H 2+O" lead toC Multifocal ostemyelitis and cellulitis ?y!ertro!ic osteoartro!aty o A.do !ain due to !seudoaneurysm !ressure Bvaluation o ?/ and !ysical UK2 .leed" lower K2 .leed 0aotoa!!endicial fistulaLto lim.1" AAA re!air" systemic signs" a.do mass" AB multifocal cellulitis o BK# H to rLo oter source of .leed" to F t !ortion o C5 o 2ndium ))) scan o Angio to define run off and renal a& location o 2n alf te cases need to e/!lore in OR 5reatment is surgicalC o 2d !resence of active emorrage o Classify AB6 H !rimary vs secondary o 2ndication for re!airC A2O# vs aneurysm 2f BtS A2O# H ten ta:e down and !atcing of te aortotomy is an attractive o!tionM o B/tent of se!sis o KoalsC Save life" ten !reserve lim.& ?owC Control emorrage Re!air K2 tract Control infection Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2*2 Canadian Vascular Surgery Minimum Maintain ade>uate distal !erfusion SurgeryC #B5A2AB# consent firstC onest" realistic" detailedM o ;%ena"io 1- 5( is b+eeding- linesLa./Lemergent surgery 5' vs retro!eritoneal R' if difficult nec: is antici!ated" o can9t see R C2A" R renal and can9t do Rigt a/,fem Su!raceliac control of .leeding first H !lace clam! .ut don9t close it until needed Medial visceral rotation vs troug te crus #istal control 'eel of duodenum" !ut a stitc to control s!illage if needed ResectLde.ride infected aorta #ecide on in,situ vs e/tra,anatomic Re!air duodenumC 'rimary" rou/,en,y" PL, gastrostomy" 4e4unostomy Assess e/tremities 2f mono!asic signalLQF0mm ?g at an:les may forego revasc o ;%ena"io 3- Jo b+eeding- Confirm diagnosis AN# rule out K2 .leed 0oter sourcesss1 C5" BK#" tagged R3C" -3C scan Consider e/tra,anatomic revasculari;ation first !rior to e/cision& o 2f !rimary AB6 H only E0O are infected May consider in,situ re!air wit life long surveylance 'ossi.le if minimal retro!eritoneal soiling and no se!sis Allows for sim!le dura.le revasculari;ation Uncertain long term !otential for infection Safer o!tion is an e/tra,anatomic re!air o 3acterial seeding in AB6 can occur in a.out 2*O of all te BA3M 6or ty!ical synttic graft" te ris: is a.out )0O&&&& o Com!osite e/tra,anatomic .y!ass H S6V to infected groins" !rostetic to a/illaM any meritD '&%)0 o Role of BVARD AimitedM may .e considered for !rimary AB6 after BVAR as .een descri.ed as wellM o Results of Aorto,Bneric fistulae re!airC Natural istory H .leeding" se!sis" deat Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2*E Canadian Vascular Surgery Minimum O!erative re!air ,E0,F0O mortality Am!utation )0O E year survival *0O TRAUMA: 318.Carotid a@ in<ury and neurologic deficit@ %"en to fix? o Jeu"o+ogi%a++$ as$m5(oma(i%, no o%%+usion , fi/ o Jeu"o as$m5(om(i%, o%%+usion Some may say 7tan: you luc:y stars8 Ruterford states re!air to !revent delayed com!lications AV6 5rom.us !ro!agation !seudoaneurysm Anticoagulate and don9t fi/ itM o Comatose" no occlusion H .e careful to rLo oter causes of coma o Foma(ose, o%%+usion , fi/ 2nitial anectodal re!orts of converting iscemic stro:e to emorragic& Concerns a.out distal em.oli;aiont during carotid re!air are unfounded according to Ruterford Controversion area .ut Ruterford suggests to e/!lore 5ry to resta.lis .ac: flow wit u! to te level of te s:ull fogart re,!erfuse if .ac:.leeding 2f can9t .ac:.leed or too e/tensive H ligate" PL, anticoagulate& All availa.le evidence suggests o5(ima+ neu"o+ogi% ou(%omes a"e ob(ained ,i(h o5e"a(i&e "e5ai" be%ause mos( de'i%i(s "emain un%hanged o" im5"o&e8 Can9t always discern te etiology of comaC alcool" meta.olic" durgs" soc:" vs vascular in4ury Comatous !ts mortality O!timal normal outcome 28 !ts ligated G0O )*O F2 !ts re!erfused 2*O *0O !&)00% Minor carotid in4uries can .e followed wit angioL#US 319.&reat!ent of .lunt carotid in<ury: o Carotid,cavernous sinus fistulae H .alloon occlusion tecni>ue Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2*F Canadian Vascular Surgery Minimum o #issection H AC alone" rigorous follow u! %0O recovery to normal function if AC started .efore neuro deficit" F0O after te onset& Survey for dilatationC o G2O reverted to normal o 2%O !rogressed to !seudoaneurysm Stents H controversial o 'seudoaneurysms Surgical re!air if easy to access or sim!le Oterwise AC" ligate" Rarely BC,2CLcervical !etrous 2CA .y!ass o Verte.ral artery in4uryC 2f !enetrating and e/sanguinatingC o 5reat it wit ligationC very little downsideM o EO cance of .rainstem stro:e if A is ligated" 2O if rigt o May try endo to occlude 2f .luntLoccludedLAV6L!seudoaneurysmC o O.serve wit AC" follow wit angio o Consider endo occlusion 0trom.osed artery in fact may .e com!letely transected1& o 5is will address concerns reC re.leeding 2f dissection H usually see in VE segment" ),2L*2 !ost traumaC 80,%0O !resent as !osterior circulation infractM '&)0)2 320.C"est *ascular trau!a: o Ascending aorta and arc H re>uire full cardio!ulmonary .y!ass" y!otermia and cardio!legic arrest AsideC arc vessels may .e reconstructed wit side .iting clam! to assending aorta and a .y!ass o #istal aortaC Clam! and sew Off load eartC Atrio,femoral .y!ass 0Most common1 A/illo,femoral 0time,consuming1 6ull cardio!ulmonary .y!ss 0used rarely1 o Aortic trauma re!air general !ointsC 're,warm room and fluids to F0 degrees 'ro/ control .tw A CCA and A SCA -atc out for vagus and toracic duct A verte.ral artery ta:es off arc in 8O of cases Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2** Canadian Vascular Surgery Minimum #o not de.ride aorta #o not sacrifice intercostals Move clam! closer to in4ury 6ine suture and :nitted graft 6or grafts ta:ing off ascending aorta" use single lim." multi!le if necessary 'remanifactured .ifurcated are too .ul:y" may not fit in anterior mediastinumM Use .ovine !ericardium to cover tis Mid+ine s(e"no(om$- he+5'u+ 5oin(s o S:in from Sternal notc to /y!oid o #evelo! retrasternal !lane a.ove and .elow" no need to connect tese o ASI anestesia to deflate lungs to minimi;e cance of !nemo o Oscilating saw o #ivide tymus o A .racioce!alic veinC 'reserve ligate its9 tyroid tri.utaries will allow mo.ili;ation of tis vessel& An(e"io" (ho"a%(om$- 'o" sub%+a&ian e75osu"e o Avoid R sided central lines H may cause !neumo H won9t .e a.le to do single lung ventilation o #ou.le lumen B5 tu.e o Su!ine" roll under A soulder and i! to .ring cest u! 20 degrees o A infra!ectoral incision o 2# * t ri." go a.ove it H F t intercostal s!ace o Ri. s!reader H may need to divide internal mammary aLv o #eflate lung" !us it down o 2# arc under mediastinal !leura o 2ncise it" !reserving A vagus nerve coursing anterolaterally over origin or ASA o 5oracic duct is !osteromedial , !reserve L .os(e"o/+a(e"a+ (ho"a%o(om$- 'o" des%ending ao"(a e75osu"e o 3ean .ag" stra! i!s" o 5rue lateral !ostion" roll under R a/illa" A arm over Mayo stand o 2ncision from .elow A ni!!le to ) inc .elow ti! of sca!ular o #ivide serratus ant" lats" tra!e;ius H slide soulder girdle u! o F t 2CS for middle descending aorta" G t 2CS for distal o Verify 2CS from a.ove .y counting o 'rotect !renic and vagus nerves coursing over arc Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2*G Canadian Vascular Surgery Minimum 321.Radiograp"ic clues to potential .lunt aortic in<ury: o Aoss of te sadow of te aorto!ulmonary :no. more s!ecific tan wide mediastinum o Aoss of !areverte.ral stri!e o Aoss of aorto!ulmonary window o #e!ression of te AMS3 Q )F0 degrees o #eviation of nasogastric tu.e o Aateral dis!lacement of tracea o A!ical ematoma o -ide midiastinum Q 8 cm o Massive left ematora/ o 6racture of te sternum" sca!ula" multi!le left ri.s" clavicle" !elvis o 3lunt in4ury to te dia!ragm 322.#ost co!!on .lunt *ascular t"oracic in<uries: #escending aorta distal to ASA 2nnominate artery 323.Conser*ati*e treat!ent of t"oracic aortic in<uries: o 5ree categories in multi!ly in4ured !ts Massive in4uries" e/sanguination on site Unsta.le during trans!ort" transient res!ondersC ig mortality rate due to multisystem trauma ?# sta.le" confined mediastinal ematomaC tese can .e o.served& #eat is due to ead in4ury o 2f cosen to o.serve" use 2m!ulse reduction tera!y MA' at minimum 0R%01 Bnsure sta.ility of mediastinal ematoma on serial imaging 't is fully informed reC ris: and .enefits Management during delay is su!ervised .y vascular surgeon o Can delay u! to +2 fi.rinous organi;ation of mediastinal clot ta:es !lace 324. A.do!inal *ascular trau!a: Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2*+ Canadian Vascular Surgery Minimum IoreanLveietnam war H EO CivilianC o 'enetratingC gun sot H )FO" sta. )0O o .lunt EO MC renal" ten SMA Retro!eritoneal ematomaC wen to e/!lore
)& B/!lore all !enetrating a8 E7%e5(ion 2 s(ab+e 5e"ine5h"i% J)T in&o+&ing (he hi+um 2& 3luntC e/!lore only if Aea:ing B/!anding 0some say only RA'2#A= e/!anding1 'ulsatile 'araduodenal Roo( o' mesen(e"$ 6i8e8 ;MA# .LH; is%hemi% bo,e+ Yone EC o 2ntra!eritoneal 3ladder in4ury o male uretral in4ury o !ulseless leg asi"e: #l!nt in$!ry to the ilia artery % lea"s to thro&#osis "!e to streth. '(P)O*' only if: +ntraperitoneal lea, '-pan"in. /#sent or "i&inishe" fe&oral p!lse p. 1039 On e-a& it is safe to si&ply "o fe&0fe&1 if there is no nee" to e-plore the a#"o&en 2an" ) he&ato&a34. 5owe6er1 in sta#le in"i6i"!al1 *!therfor" s!..ests e-ploration an"1 possi#ly1 iliofe&oral #ypass35e&o"yna&i an" pateny res!lt of fe&0fe& in a yo!n. pt is 7/* inferior to iliofe&. 7or +liofe& % !se 879 if onta&ination3 :!t for e-a& p!rpose1 "o not "o iliofe& % will #e too onta&inate" for the prostheti1 an" will ta,e too lon. to .et 879. Une/!lored ematomas are to .e followed .y #o!!ler and #o!!ler& Bnteric s!illage is not contraindication to !rosteticsC so consider e/trananatomic .y!ass only in case of !urulent !eritonitis and infected graft 0Ruterford1 Multi!le trauma e/!erience suggests safety of !rostetics even in te face of entric contamination& Cover tis wit grafts Su!ra mesocolic a&control H Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2*8 Canadian Vascular Surgery Minimum o A visceral rotation" dia!ragmatic control" A cest 2nframesocolic , o 5ransverse colon reflected ce!alad" small .owel to te R& SMA H retro!ancreatic !ortion 0may transect nec:" or su!raceliac !ro/imal control1" infra!ancreatic !ortion 0retract !ancreas u!1& -en to ligate aortic .rancesC SMA H only in te !resence of necrotic .owel AN# only at te origin H a.ove gastroduodenal and inferior !ancreatico,duodenal arcade& o Blsewere H ig incidence of .owel iscemia& Celiac H o: if SMA is o: C?A H !ro/imal to ta:e off of K#A& A renal vein ligation at 2VC is tolerated well" R renal vein ligation is always followed .y ne!rectomy& NBVBR ligate C2A or B2A witout reconstruction" even in !ts in critical condition& o 'lace tem!orary sunt if necessary& May ligate iliac veins H o 2f re!air will result in stenosis Q *0O o 'ro!ylactic fasciotomies are controversial o No role for com!le/ s!iral graft reconstructions 2VC H may ligate if infrarenal o -ra! and elevate legsM Renal a& in4ury H revasculari;e if o witin G " if single or o witin 20 if SOAB :idney in4ury or .ilateral damage autorities vary on e/act timing Success of revasculari;ation is !oor at a.out E0O&&& o in )2,*0O of revasculari;ed !ts y!ertension develo!s o 2f non,revasculari;ed" ?5N develo!s in E0,F0O witin ) mont to a year" mean E mont Some recommend surgery for Renal Artery re!air only inC o 2ntrao!erative identification of renal artery in4ury o Sta.le !t o Solitary :idney !resent or .ilateral in4ury o 5e rest H monitor for y!ertensionM Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2*% Canadian Vascular Surgery Minimum 325.xtre!ity trau!a notes: o Most common ty!e of vascular trauma 080O of all ty!es1 'enetrating %0O" .lunt )0O o ?ard signs H go to OR" a!arini;e if !ossi.le o Angiogram indications in e/tremity traumaC Significant .lunt in4ury wit `Ldislocation AN# signs of iscemia A32 R) Multi!le !enetrating wounds '&)00E o Angio is %2,%8O accurate" most errors involve false !ositive o Always ave glo.al a!!roac to trauma rLo O5?BR vascular in4ury rLo oter NON,vascular in4ury assess neurologic and antici!ated 6UNC52ONAA status of e/tremity i&e& mangled e/tremity cec:& ?ard signsC Any of G 7'8 o 'ain o 'allor o 'ulseless o 'arestesia o 'oi:ilotermia o !aralysis Ongoing .leed o B/ternal o 2nternalC 'ulsatile ematoma 3ruits and trill o AV6 Soft signsC o #istal !ulse deficit o A32 R ) o 'resence of soft signs of arterial in4ury !ro/imity to ma4or vessels Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2G0 Canadian Vascular Surgery Minimum small non,!ulsatile non,e/!anding ematoma Lo !reos!ital .leedLsoc: !eri!eral nerve deficit fracture dislocation Minimal in line intimal angio in4ury H
intimal fla!"segmental narrowing" ?# insig AV6L!seudoaneurysms H eal witout surgery can .e serially o.served wit du!le/Langio& Non essential vesselsLaneurysms can .e em.oli;ed& noteC for !ro/imity to ma4or vessel in4ury" most would do serial A32 only" no angio& Occult in4uryC 2f cose to o.serve" must .e a.le to follow wit !ysical e/am and du!le/& Missed in4ury seen in only 2,EO of cases 0Osler1 'osterior :nee dislocationC Reduce first Cec: iscemiaL!ulses B/!lore if no !ulse after reduction or iscemia 2f A32 is reduced .ut no iscemia H angiogram ,Q fi/ only ma4or !ro.lems& 326.&rau!atic A-1: 2atrogenic 0!ost !rocedure1 Non,iatrogenic 0true trauma1 2f central in origin" unli:ely to close" so will re>uire re!air& 2f !eri!eral and is NO5 associated wit true trauma 0i&e& iatrogenic origin !ost needle stic:1" %0O will close in F monts 0average lengt of closure is 28 days1& 2ndication for re!airC 6luid overload o Venous ?5N o C?6 #istal iscemia Non,com!liant !atient Central locationLnec: 'ost trauma 0as o!!osed to !rocedure1 Keneral recommendation is to wait F monts unless tere are indications 0a.ove1& Re!air failures& 'ro/imal and distal control& B/!ect ma4or .lood loss& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2G) Canadian Vascular Surgery Minimum 2f in mid S6A H consider sort covered stentM May try US guided occlusion& Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2G2 Canadian Vascular Surgery Minimum Canadian Vascular Surgery Minimum, Review notes, U of Ottawa, Anton Sharapov, MD age 2GE