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ABSITE REVIEW Vascular

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ABSITE REVIEW Vascular Jessica O Connell, MD January 25, 2012 * * * * A 45-year-old woman undergoes angiography for severe hypertension, as shown. – PowerPoint PPT presentation

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Title: ABSITE REVIEW Vascular


1
ABSITE REVIEW Vascular
  • Jessica OConnell, MD January 25, 2012

2
Q0
  • Question Most common cranial nerve injured
    during CEA?
  •  
  •   Vagus nerve (hoarseness)
  • Question Other cranial nerves injured during
    CEA?   
  • Hypoglossal nerve
  • tongue deviation toward side of injury
  • swallowing/mastication/speech difficulty
  •   
  • Question What happens if you cut the Ansa
    Cervicalis
  •   
  • no serious deficits
  • innervates strap muscles

3
P1
  • Carotid-body tumor
  • Blood supply from ECA
  • splaying of carotid bifurcation (lyre sign)

4
Q3
  • A 58-year-old man has multiple sores on his right
    lower leg, as shown. He is diabetic and
    hypertensive. He can only walk 1 block before
    becoming dyspneic. He first noted the sores about
    2 months ago.
  • On physical examination he has an ulceration
    measuring 3 x 5 cm on the anteromedial aspect of
    his right lower leg above the medial malleolus.
    The surrounding skin is brawny with hemosiderin
    deposition. Similar skin changes are noted on the
    anteromedial aspect of the left lower leg. He has
    palpable dorsalis pedis pulses bilaterally.
  • The most effective nonoperative therapy for this
    patient would be
  • elastic compression stockings (Jobst)
  • paste gauze (Unna) boot
  • polyurethane foam dressings
  • hydrocolloid dressings (DuoDerm)
  • intermittent pneumatic compression

5
Q3
  • A 58-year-old man has multiple sores on his right
    lower leg, as shown. He is diabetic and
    hypertensive. He can only walk 1 block before
    becoming dyspneic. He first noted the sores about
    2 months ago.
  • On physical examination he has an ulceration
    measuring 3 x 5 cm on the anteromedial aspect of
    his right lower leg above the medial malleolus.
    The surrounding skin is brawny with hemosiderin
    deposition. Similar skin changes are noted on the
    anteromedial aspect of the left lower leg. He has
    palpable dorsalis pedis pulses bilaterally.
  • The most effective nonoperative therapy for this
    patient would be
  • elastic compression stockings (Jobst)
  • paste gauze (Unna) boot
  • polyurethane foam dressings
  • hydrocolloid dressings (DuoDerm)
  • intermittent pneumatic compression

6
Q3
  • venous stasis ulcers
  • trial of nonoperative therapy is indicated in
    this high-risk surgical patient
  • Compressive therapy
  • paste gauze (Unna) boots are superior to elastic
    compression stockings (Jobst), polyurethane foam
    dressings, and elastic compression wraps,
    hydrocolloid (DuoDerm)
  • combination of intermittent pneumatic compression
    (IPC) stockings and elastic compression wraps
    superior to elastic compression
  • However, the IPC patients also had periods of leg
    elevation, which may have influenced the healing
    rates
  • IPC stockings alone have not been compared with
    Unna boots

7
Q38
  • Please view the image, then select the best
    answer.
  • An arteriovenous fistula (AVF) that usually
    requires transposition (superficialization) of
    the venous outflow
  • AVF that has patency rate equivalent to the
    Brescia-Cimino fistula
  • Both
  • Neither

8
Q38
  • Please view the image, then select the best
    answer.
  • An arteriovenous fistula (AVF) that usually
    requires transposition (superficialization) of
    the venous outflow
  • AVF that has patency rate equivalent to the
    Brescia-Cimino fistula
  • Both
  • Neither

9
Q39
  • Please view the image, then select the best
    answer.
  • An arteriovenous fistula (AVF) that usually
    requires transposition (superficialization) of
    the venous outflow
  • AVF that has patency rate equivalent to the
    Brescia-Cimino fistula
  • Both
  • Neither

10
Q39
  • Please view the image, then select the best
    answer.
  • An arteriovenous fistula (AVF) that usually
    requires transposition (superficialization) of
    the venous outflow
  • AVF that has patency rate equivalent to the
    Brescia-Cimino fistula
  • Both
  • Neither

11
Q40
  • Please view the image, then select the best
    answer.
  • An arteriovenous fistula (AVF) that usually
    requires transposition (superficialization) of
    the venous outflow
  • AVF that has patency rate equivalent to the
    Brescia-Cimino fistula
  • Both
  • Neither

12
Q40
  • Please view the image, then select the best
    answer.
  • An arteriovenous fistula (AVF) that usually
    requires transposition (superficialization) of
    the venous outflow
  • AVF that has patency rate equivalent to the
    Brescia-Cimino fistula
  • Both
  • Neither

13
Q38-40
  • 38 is the normal anatomy of the right antecubital
    fossa
  • 39 is the brachial artery to cephalic vein
    fistula, probably the most commonly used
  • 40 is brachial artery to basilic vein fistula
  • In a study comparing the three types of fistulas,
    all had patency rates comparable to the forearm
    radiocephalic fistula
  • the brachial artery to basilic vein required
    transposition of the outflow vein (the brachial
    vein) into the subcutaneous position

14
Q1
15
Q1
16
Q1
17
Q1
18
Q4
  • A 53-year-old man has a 1-week history of a
    painful blue right first toe. Before his toe
    turned blue, he was able to climb 4 flights of
    stairs without difficulty. On physical
    examination, his first toe is bluish, and he has
    palpable pedal pulses bilaterally. He complains
    of numbness and tingling below the knee. He also
    has a palpable pulsatile mass in his right
    popliteal fossa. Ultrasound examination confirms
    the presence of a 4-cm right popliteal aneurysm.
  • The most appropriate treatment would be
  • systemic anticoagulation
  • ligation of the aneurysm with bypass graft
  • endovascular stent
  • operative resection of the aneurysm with primary
    repair
  • aneurysmorrhaphy with interposition graft

19
Q4
  • A 53-year-old man has a 1-week history of a
    painful blue right first toe. Before his toe
    turned blue, he was able to climb 4 flights of
    stairs without difficulty. On physical
    examination, his first toe is bluish, and he has
    palpable pedal pulses bilaterally. He complains
    of numbness and tingling below the knee. He also
    has a palpable pulsatile mass in his right
    popliteal fossa. Ultrasound examination confirms
    the presence of a 4-cm right popliteal aneurysm.
  • The most appropriate treatment would be
  • systemic anticoagulation
  • ligation of the aneurysm with bypass graft
  • endovascular stent
  • operative resection of the aneurysm with primary
    repair
  • aneurysmorrhaphy with interposition graft

20
Q4
  • thromboembolic complication from a large
    popliteal aneurysm
  • A combined review of 536 asymptomatic patients
    with popliteal aneurysm, with a mean follow-up of
    approximately 4 years, 35 developed
    thromboembolic complications. The associated
    amputation rate was 25.
  • Most complications occur in aneurysms with
    diameters gt 2 cm
  • early operation for asymptomatic aneurysms larger
    than 2 cm is indicated.
  • Surgical techniques
  • exclusion of the aneurysm with a bypass graft.
    The aneurysm is ligated proximally and distally,
    then continuity is re-established using an
    extra-aneurysmal bypass graft
  • Aneurysmorhapy with interposition graft, the
    aneurysm can be incised, followed by ligation of
    any collateral vessels, and then the bypass graft
    is placed within the bed of the aneurysm
  • indicated for larger aneurysms causing any
    compressive symptoms - lower leg pain, numbness,
    paresthesia, venous congestion, and edema.
  • eliminates the possibility of recurrence or
    continued expansion of the aneurysm.
  • Vascular stent-graft - stents at the knee in a
    younger person with a low operative risk ??
    durability and long-term patency still under
    question

21
Q5
  • A 28-year-old female body builder has the acute
    onset of a swollen right arm. Which of the
    following statements about her condition is TRUE?
  • Higher incidence in females
  • Often accompanied by neurologic symptoms
  • Not successfully treated with anticoagulation
    therapy
  • Definitively treated with catheter-directed
    thrombolysis
  • Associated with venous gangrene of the upper
    extremities

22
Q5
  • A 28-year-old female body builder has the acute
    onset of a swollen right arm. Which of the
    following statements about her condition is TRUE?
  • Higher incidence in females
  • Often accompanied by neurologic symptoms
  • Not successfully treated with anticoagulation
    therapy
  • Definitively treated with catheter-directed
    thrombolysis
  • Associated with venous gangrene of the upper
    extremities

23
Q5
  • primary axillary-subclavian vein thrombosis
  • young patients, 21 malefemale ratio
  • strenuous or repetitive upper extremity activity
  • compression of the subclavian vein at the
    thoracic outlet
  • often becomes chronic, debilitating venous
    outflow obstruction
  • Neurologic symptoms do not usually accompany
    primary venous thrombosis, because the vein and
    nerves are at the opposite ends of the thoracic
    outlet.
  • traditional treatment elevation of upper
    extremity/anticoagulation
  • persistent symptoms in up to 80
  • catheter-directed
  • followed by dynamic venography
  • operative thoracic outlet decompression

24
Q5
  • Thoracic Outlet
  • Subclavian vein
  • Passes over 1st rib
  • Anterior to anterior scalene m.
  • Behind clavicle
  • Brachial plexus Subclavian artery
  • Pass over 1st rib
  • Posterior to anterior scalene m.
  • Anterior to middle scalene m

25
  • Thoracic Outlet Exam

Q5
Adson maneuvers While the patient is in a
sitting position, ask the patient to inspire
deeply, hold his breath, and extend his neck.
Then, turn the patient's head passively as far as
possible toward one side and then the other. When
the head is turned toward the unaffected side, or
sometimes the affected side, obliteration of the
radial pulse with a drop in blood pressure in the
arm is considered a positive result. Roos
maneuver When in the surrender posture, the
patient reports paresthesia and numbness in
extremities within 1 minute. This maneuver
usually provokes symptoms in lateral cord
distribution. Elevated-arm stress test In this
test, the patient keeps arms abducted with flexed
elbows for 3 minutes while flexing and extending
the fingers. Results are considered positive if
the patient cannot do this for 3 minutes. Wright
maneuver This maneuver requires the patient to
hold the arms next to the ears. Paresthesias
usually are noted down the medial scapular border
and into lower trunk distribution. Hyperabduction
test The radial pulse is diminished after
elevating the involved arm above the
head. Military maneuver (ie, costoclavicular
bracing) This maneuver provokes symptoms when
the patient elevates the chin and pulls the
shoulder joint behind in an extreme "attention"
position.
26
Q1
  • Question Which nerve/artery is commonly
    injured with fracture of
  • the mid-shaft humerus?
  •  
  •   Radial nerve
  • Question Which nerve/artery is commonly injured
    with supracondylar fracture of the humerus?
  •   
  • Brachial artery
  •   
  • Question Which nerve/artery is commonly injured
    with distal radius fracture?
  •   
  • Median nerve

27
Q6
  • A 44-year-old man with diabetes mellitus
    complicated by peripheral neuropathy presents
    with malaise, leukocytosis, and hyperglycemia. He
    has received 1 week of antibiotic therapy. The
    plantar surface of the foot is pictured.
  • Which of the following statements about
    management of this problem is TRUE?
  • Fever is a reliable indicator of the severity of
    infection
  • Antimicrobial therapy alone will resolve 50 of
    cases
  • Swab cultures of purulent drainage are adequate
  • Magnetic resonance imaging (MRI) will not
    reliably diagnose osteomyelitis in this patient
  • Immediate transmetatarsal amputation is required

28
Q6
  • A 44-year-old man with diabetes mellitus
    complicated by peripheral neuropathy presents
    with malaise, leukocytosis, and hyperglycemia. He
    has received 1 week of antibiotic therapy. The
    plantar surface of the foot is pictured.
  • Which of the following statements about
    management of this problem is TRUE?
  • Fever is a reliable indicator of the severity of
    infection
  • Antimicrobial therapy alone will resolve 50 of
    cases
  • Swab cultures of purulent drainage are adequate
  • Magnetic resonance imaging (MRI) will not
    reliably diagnose osteomyelitis in this patient
  • Immediate transmetatarsal amputation is required

29
Q6
  • Foot ulcers occur in 15 of all patients with
    diabetes
  • chronic immunosuppression that accompanies
    diabetes mellitus, the usual physical signs and
    symptoms of infection are often not present
  • Diabetic foot wounds must first be probed
  • underlying sinus tracts or abscesses
  • deep or proximal extension along fascial planes
  • bones and joints involvement
  • Probing to bone PPV 89 for osteomyelitis in
    diabetic foot infections
  • frequently neuropathic patients.
  • mixed infections - broad-spectrum antibiotisc
  • Staphylococcus aureus, Streptococcus,
    Enterobacter, and Bacteroides fragilis
  • MRI sensitive and specific indicator of true bone
    marrow infection
  • previous trauma, operation, or Charcot
    osteoarthropathy reduces the specificity
  • combining bone scintigraphy with leukocyte scans
    - specificity gt80.
  • Management
  • avoidance of weightbearing
  • immediate drainage and debridement procedures
  • hyperglycemic control
  • management of ischemia

30
Q8
  • A 56-year-old diabetic man with a history of
    transmetatarsal amputation presents with fever,
    chills, fatigue, malaise, leukocytosis, and
    hyperglycemia. His transmetatarsal amputation
    site is pictured. The dorsalis pedis and
    posterior tibial pulses are absent.
  • Proper management of this condition would be
    broad-spectrum antibiotics and
  • revision of transmetatarsal amputation
  • immediate surgical debridement of soft tissue
    only
  • immediate surgical debridement, and vascular
    reconstruction of pedal blood flow
  • immediate surgical debridement, with negative
    pressure dressing to improve blood flow
  • immediate below-knee amputation

31
Q8
  • A 56-year-old diabetic man with a history of
    transmetatarsal amputation presents with fever,
    chills, fatigue, malaise, leukocytosis, and
    hyperglycemia. His transmetatarsal amputation
    site is pictured. The dorsalis pedis and
    posterior tibial pulses are absent.
  • Proper management of this condition would be
    broad-spectrum antibiotics and
  • revision of transmetatarsal amputation
  • immediate surgical debridement of soft tissue
    only
  • immediate surgical debridement, and vascular
    reconstruction of pedal blood flow
  • immediate surgical debridement, with negative
    pressure dressing to improve blood flow
  • immediate below-knee amputation

32
Q8
  • clinically infected, gangrenous transmetatarsal
    amputation
  • systemic signs and symptoms of sepsis, including
    leukocytosis and hyperglycemia
  • absence of dorsalis pedis and posterior tibial
    pulses
  • immediate need halt the spread of sepsis before
    fatal
  • immediate broad-spectrum antibiotic therapy
  • immediate guillotine amputation
  • once the sepsis is controlled, revision of the
    amputation can be undertaken
  • negative pressure dressings do not improve blood
    flow to ischemic tissues

33
P2
DeBakey Classification Aortic Dissection
34
Q9
  • Which of the following statements about
    antithrombotic treatments is TRUE?
  • In the absence of antithrombin III,
    unfractionated heparin has no significant
    anticoagulant effect
  • Low molecular weight heparins share the ability
    to accelerate the activity of factor Xa
  • Warfarin inhibits the absorption of vitamin K
    from the intestinal tract
  • Hirudin, a synthetic thrombin inhibitor, is
    dependent on antithrombin III for anticoagulant
    activity
  • The addition of aspirin to heparin increases the
    anticoagulant effect without increasing the risk
    of hemorrhagic side effects

35
Q9
  • Which of the following statements about
    antithrombotic treatments is TRUE?
  • In the absence of antithrombin III,
    unfractionated heparin has no significant
    anticoagulant effect
  • Low molecular weight heparins share the ability
    to accelerate the activity of factor Xa
  • Warfarin inhibits the absorption of vitamin K
    from the intestinal tract
  • Hirudin, a synthetic thrombin inhibitor, is
    dependent on antithrombin III for anticoagulant
    activity
  • The addition of aspirin to heparin increases the
    anticoagulant effect without increasing the risk
    of hemorrhagic side effects

36
Q9
  • Unfractionated heparin - indirect thrombin
    inhibitor
  • acceleration of the interaction of antithrombin
    III with thrombin (factor IIa)
  • In the absence of antithrombin, unfractionated
    heparin has no significant antithrombotic effect
  • Antithrombin III levels can be increased by the
    infusion of fresh frozen plasma
  • low molecular weight heparins - inhibition of
    factor Xa
  • down-regulation of thrombin production
  • Warfarin - inhibits vitamin K-dependent terminal
    carboxylation of factors II, VII, IX, and X in
    the liver
  • oral anticoagulant, no impact on GI absorption of
    vitamin K
  • Hirudin - direct thrombin inhibitor
  • isolated from the saliva of the medical leech,
    reproduced with recombinant technology
  • not dependent on the activity of antithrombin III
  • heparin-associated antibodies

37
Q10
  • Which of the following statements about
    management of abdominal aortic aneurysm (AAA) is
    TRUE?
  • Elective operation should be considered for
    patients with symptomatic AAA in the absence of
    significant co-morbidities
  • The risk of rupture is higher in women than men
    for small aneurysms
  • In an otherwise healthy 75-year-old man, a 4.5-cm
    aneurysm should be repaired
  • An unreliable patient who is unlikely to comply
    with lifelong surveillance should be
    preferentially offered endograft versus open
    repair
  • Mortality is not related to the hospital's volume
    of AAA repairs performed

38
Q10
  • Which of the following statements about
    management of abdominal aortic aneurysm (AAA) is
    TRUE?
  • Elective operation should be considered for
    patients with symptomatic AAA in the absence of
    significant co-morbidities
  • The risk of rupture is higher in women than men
    for small aneurysms
  • In an otherwise healthy 75-year-old man, a 4.5-cm
    aneurysm should be repaired
  • An unreliable patient who is unlikely to comply
    with lifelong surveillance should be
    preferentially offered endograft versus open
    repair
  • Mortality is not related to the hospital's volume
    of AAA repairs performed

39
Q10
  • The mortality of untreated rupture of abdominal
    aortic aneurysms (AAA) approaches 100
  • AAA presenting with abdominal and/or back pain
    (most common) should be repaired urgently in
    almost all patients regardless of co-morbidity
  • UK Small Aneurysm Trial
  • significantly higher risk of rupture for small
    aneurysms in women compared with men
  • Patients undergoing endograft repair of AAA must
    be willing to comply with rigorous lifelong
    surveillance
  • graft migration, endoleak, and limb obstruction
  • annual risk of rupture 4.5-cm AAA in a
    75-year-old man is 1 per year - VA-sponsored
    Aneurysm Detection and Management (ADAM) trial
  • No survival advantage for open repair of small
    (4.0 to 5.5 cm) AAA in two large trials in both
    the United States (ADAM) and Great Britain (UK
    Small Aneurysm Trial)
  • The average life expectancy for an 80-year-old
    man after successful repair of AAA is
    approximately 7 years, or about half the life
    expectancy for an age-matched man without AAA
    repair
  • Mortality is lower with higher hospital volume

40
Q2
  • Question Which nerve/artery is commonly injured
    with supracondylar
  • fracture of femur?
  •  
  •   Popliteal artery
  • Question Which nerve/artery is commonly injured
    with posterior
  • dislocation of hip?
  •   
  • Sciatic nerve
  •   
  • Question Which nerve/artery is commonly injured
    with posterior
  • dislocation of knee?
  •   
  • Popliteal artery

41
Q12
  • Which of the following statements about the
    natural history of intermittent claudication is
    TRUE?
  • Five-year survival is gt 90
  • Most patients eventually require
    revascularization to avoid amputation
  • One in 4 patients will eventually undergo major
    amputation
  • Intermittent claudication is a risk factor for
    adverse cardiovascular events
  • Abstinence from tobacco does not improve the
    symptoms of intermittent claudication

42
Q12
  • Which of the following statements about the
    natural history of intermittent claudication is
    TRUE?
  • Five-year survival is gt 90
  • Most patients eventually require
    revascularization to avoid amputation
  • One in 4 patients will eventually undergo major
    amputation
  • Intermittent claudication is a risk factor for
    adverse cardiovascular events
  • Abstinence from tobacco does not improve the
    symptoms of intermittent claudication

43
Q12
  • claudication derived from the root word "to limp
  • reproducible leg pain relieved with rest
  • anklebrachial index (ABI) -ratio of ankle
    pressure to arm pressure
  • normal 0.9 to 1.2
  • Peripheral arterial disease, ABI lt 0.9
  • 25 of elderly patients seen in primary care (1/2
    asymptomatic)
  • Intermittent claudication is relatively benign
  • amputation (5 to 7)
  • 25 of patients need intervention
  • marker for patients at risk of future adverse
    cardiovascular events
  • modifying the risk factors of systemic
    atherosclerosis
  • smoking, obesity, hypertension, diabetes, and
    hyperlipidemia
  • The 5-year mortality 30 to 50, due to
    cardiovascular events
  • Smoking cessation improves the symptoms

44
Q12
  • Ankle Brachial index (ABI)
  • ratio of ankle pressure to arm pressure
  • Ankle Arm Index (AAI)
  • normal 0.9 to 1.2
  • Peripheral arterial disease, ABI lt 0.9
  • Claudication 0.40.9
  • Rest pain 0.20.5
  • Tissue loss lt 0.4
  • Gangrene lt 0.3
  • gt 0.50 in 85 of patients with single level of
    disease
  • lt 0.50 in 95 with two or more levels of disease

45
Q13
  • A 30-year-old man presents with a brief history
    of crampy, midabdominal pain. Physical
    examination is notable for diffuse mild
    tenderness, but frank signs of peritonitis are
    absent. Computed tomographic (CT) scan suggests
    findings consistent with mesenteric venous
    thrombosis.
  • The initial recommended treatment for symptomatic
    mesenteric venous thrombosis is
  • venous thrombectomy
  • anticoagulation with heparin
  • tissue plasminogen activator (tPA) via the
    superior mesenteric artery
  • warfarin (Coumadin) anticoagulation
  • systemic tPA

46
Q13
  • A 30-year-old man presents with a brief history
    of crampy, midabdominal pain. Physical
    examination is notable for diffuse mild
    tenderness, but frank signs of peritonitis are
    absent. Computed tomographic (CT) scan suggests
    findings consistent with mesenteric venous
    thrombosis.
  • The initial recommended treatment for symptomatic
    mesenteric venous thrombosis is
  • venous thrombectomy
  • anticoagulation with heparin
  • tissue plasminogen activator (tPA) via the
    superior mesenteric artery
  • warfarin (Coumadin) anticoagulation
  • systemic tPA

47
Q13
  • diagnosis of mesenteric venous thrombosis
    increasing frequency CT imaging
  • hypercoagulable w/u recommended
  • Long-term anticoagulation in asymptomatic
    patients NOT generally recommended
  • symptomatic patient, treatment is clearly
    indicated
  • thrombolytic agents has not definitively
    demonstrated to accelerate the lysis of
    mesenteric venous thrombosis or improve the
    clinical outcome
  • Systemic anticoagulation with intravenous heparin
    and fluid resuscitation are the mainstays of
    therapy
  • Surgical exploration - signs of abdominal
    catastrophe
  • The apparent lethality of mesenteric venous
    thrombosis has decreased during the last decade
    due to earlier detection and treatment
  • Mesenteric venous thrombosis lt10 of clinically
    significant mesenteric ischemia
  • A hypercoagulable state gt 90 of patients

48
Q14
  • A 75-year-old man with a ruptured abdominal
    aortic aneurysm, as shown, is taken urgently to
    the operating room for repair
  • Which of the following has the most important
    influence on operative mortality?
  • Distance from patient's home to hospital
  • Number of co-morbidities
  • Surgeon experience
  • Annual hospital volume of aneurysm repair
  • Site of aortic rupture

49
Q14
  • A 75-year-old man with a ruptured abdominal
    aortic aneurysm, as shown, is taken urgently to
    the operating room for repair
  • Which of the following has the most important
    influence on operative mortality?
  • Distance from patient's home to hospital
  • Number of co-morbidities
  • Surgeon experience
  • Annual hospital volume of aneurysm repair
  • Site of aortic rupture

50
Q14
  • Ruptured abdominal aortic aneurysms (AAA) overall
    mortality rate of 90
  • operative mortality arrive at the hospital alive
    50
  • but a number of factors influence the 30-day
    mortality
  • population studies advanced patient
    significantly associated with mortality however,
    race, distance from home to hospital, and medical
    complexity were not significant factors
  • surgeon experience gt 10 ruptured AAA had a
    significantly lower mortality rate
  • annual volume of elective AAA repairs did not
    influence outcome, nor did hospital volume of
    ruptured or elective AAA repair

51
Q15
  • A 78-year-old man who has the arteriogram shown
    is being evaluated for endovascular repair of a
    6.5-cm aortic aneurysm. To deploy the endograft
    safely, the left limb of the graft must be
    extended directly into the left external iliac
    artery. To prevent an endoleak, the left
    hypogastric artery should be occluded using coil
    embolization.
  • The most likely adverse event associated with
    occlusion of the left hypogastric artery is
  • buttock claudication
  • buttock necrosis
  • spinal cord ischemia
  • ischemic colitis
  • impotence

52
Q15
  • A 78-year-old man who has the arteriogram shown
    is being evaluated for endovascular repair of a
    6.5-cm aortic aneurysm. To deploy the endograft
    safely, the left limb of the graft must be
    extended directly into the left external iliac
    artery. To prevent an endoleak, the left
    hypogastric artery should be occluded using coil
    embolization.
  • The most likely adverse event associated with
    occlusion of the left hypogastric artery is
  • buttock claudication
  • buttock necrosis
  • spinal cord ischemia
  • ischemic colitis
  • impotence

53
Q15
  • Endovascular aortic aneurysm repair (EVAR) has
    become a standard treatment option for aortoiliac
    aneurysms
  • As devices have improved, challenging vascular
    anatomy short aneurysm necks and small iliac
    arteries
  • Successful treatment - graft device creates a
    seal proximal and distal ends
  • distal end (landing zone) problem with common
    iliac aneurysms that extend to the bifurcation -
    type I endoleak
  • pelvic ischemia a concern if internal iliac
    artery occluded
  • increasing experience - interruption of a single
    internal iliac artery usually well tolerated
  • coil occlusion or occluding device in internal
    iliac artery, ipsilateral graft limb into
    external iliac artery beyond the bifurcation
  • Most patients completely asymptomatic, but 25 to
    30 temporary ipsilateral buttock claudication
  • Persistent buttock claudication 10 to 15
  • Buttock necrosis, ischemic colitis, spinal cord
    ischemia, and impotence have all been reported,
    but are rare complications
  • bilateral internal iliac artery occlusion has
    been reported to be well tolerated in some
    patients, most recommend maintaining flow in at
    least one internal iliac artery
  • Internal iliac bypass
  • Snorkel technique??

54
Endovascular Repair of an Abdominal Aortic
Aneurysm, with the Use of an Endograft
Greenhalgh R and Powell J. N Engl J Med
2008358494-501
55
The 5 Types of Leakage of Blood into the
Aneurysm, or Endoleak
56
The Four Types of Leakage of Blood into the
Aneurysm, or Endoleak
Greenhalgh R and Powell J. N Engl J Med
2008358494-501
57
Q16
  • Two days after placement of a brachiocephalic
    fistula for hemodialysis access, a 53-year-old
    man has extensive edema of the ipsilateral
    extremity from the hand to the shoulder.
    Venography confirms a stenosis in the proximal
    subclavian vein creating an 85 diameter loss.
  • The best management would be
  • chronic oral anticoagulation
  • fistula ligation
  • fistula banding near the arterial anastomosis
  • balloon angioplasty of the subclavian vein
    stenosis
  • subclavian-jugular venous bypass

58
Q16
  • Two days after placement of a brachiocephalic
    fistula for hemodialysis access, a 53-year-old
    man has extensive edema of the ipsilateral
    extremity from the hand to the shoulder.
    Venography confirms a stenosis in the proximal
    subclavian vein creating an 85 diameter loss.
  • The best management would be
  • chronic oral anticoagulation
  • fistula ligation
  • fistula banding near the arterial anastomosis
  • balloon angioplasty of the subclavian vein
    stenosis
  • subclavian-jugular venous bypass

59
Q16
  • Pain and swelling in extremity after placement of
    an arteriovenous access is indicative of venous
    hypertension
  • hemodynamically significant stenosis in the
    central venous system, usually due to previous
    central venous catheterization
  • subclavian vein, innominate vein, axillary vein,
    and superior vena cava
  • Long-term oral anticoagulation will not result in
    symptomatic improvement
  • ligating the fistula, but sacrifices a
    functioning access
  • External banding will reduce flow in the fistula,
    but continued venous hypertension is likely
  • Correction of the venous hypertension requires
    treatment of the central vein stenosis
  • endovascular options may be a reasonable
    alternative, balloon angioplasty of central vein
    stenoses is associated with early recurrence in
    most cases
  • Multiple procedures are often required
  • long-term relief lt1/3 patients
  • Open surgical techniques such as
    subclavian-jugular bypass or jugular turndown
    (jugular subclavian vein transposition) better
    option, especially in younger patients with
    reasonable long-term prognosis
  • Although more invasive, long-term patency and
    symptomatic relief are better than with
    angioplasty

60
Q17
  • A 78-year-old woman with chronic atrial
    fibrillation is admitted with a 2-hour history of
    severe midepigastric abdominal pain that began
    suddenly. Her abdomen is nontender on physical
    examination. An abdominal computed tomographic
    (CT) scan obtained in the emergency department is
    shown.
  • The next step in management should be
  • mesenteric arteriogram
  • biliary excretion, eg, HIDA, scan
  • systemic urokinase
  • anticoagulation and
  • serial examination
  • exploratory laparotomy

61
Q17
  • A 78-year-old woman with chronic atrial
    fibrillation is admitted with a 2-hour history of
    severe midepigastric abdominal pain that began
    suddenly. Her abdomen is nontender on physical
    examination. An abdominal computed tomographic
    (CT) scan obtained in the emergency department is
    shown.
  • The next step in management should be
  • mesenteric arteriogram
  • biliary excretion, eg, HIDA, scan
  • systemic urokinase
  • anticoagulation and
  • serial examination
  • exploratory laparotomy

62
Q17
  • Acute mesenteric ischemia sudden onset of severe,
    unrelenting abdominal pain
  • In the early stages, abdominal examination is
    relatively benign
  • nonspecific diagnostic findings usually result in
    delay in
  • Embolic occlusion 25 of all cases - nearly all
    cardiogenic - Atrial fibrillation
  • Acute mesenteric insufficiency - in situ
    thrombosis of a pre-existing stenosis in the
    superior mesenteric artery (SMA) in 65
  • Nonocclusive mesenteric ischemia 10
  • arteriography and computed tomography (CT)
  • exploratory laparotomy without delay
  • time to re-establishing SMA flow is the most
    important
  • peritonitis associated with high mortality rate
  • Lytic therapy may be used to buy time if
    operation is delayed, delivered through a
    catheter in SMA

63
Q18
  • Five days after an uncomplicated right carotid
    endarterectomy, a 69-year-old man arrives in the
    emergency department after the sudden onset of a
    severe right-sided headache. He is
    hemodynamically normal and neurologically intact.
  • The next step in management should be
  • administration of intravenous heparin
  • carotid duplex ultrasonography
  • cerebral imaging study
  • carotid arteriogram
  • immediate transport to the operating room for
    carotid re-exploration

64
Q18
  • Five days after an uncomplicated right carotid
    endarterectomy, a 69-year-old man arrives in the
    emergency department after the sudden onset of a
    severe right-sided headache. He is
    hemodynamically normal and neurologically intact.
  • The next step in management should be
  • administration of intravenous heparin
  • carotid duplex ultrasonography
  • cerebral imaging study
  • carotid arteriogram
  • immediate transport to the operating room for
    carotid re-exploration

65
Q18
  • Hyperperfusion syndrome of the brain - rare but
    potentially dangerous complication of carotid
    endarterectomy (CEA) or carotid artery stenting
  • often heralded by severe ipsilateral headache
  • progress to seizure activity and cerebral
    hemorrhage
  • prevalence after CEA 0.4 to 7.7, depending on
    the definitions used
  • Hyperperfusion is believed to represent increased
    cerebral blood flow in a territory with disturbed
    autoregulation
  • Proposed risk factors
  • correction of a very high grade carotid stenosis
    (especially when the contralateral carotid artery
    is occluded)
  • previous stroke
  • poor collateral blood supply
  • uncontrolled hypertension
  • suspected in any patient with severe ipsilateral
    headache after CEA/CAS
  • Imaging to evaluate edema or hemorrhage
  • CT hemorrhage
  • MRI with gadolinium enhancement particularly
    sensitive for subtle changes associated with
    hyperperfusion
  • risk of cerebral hemorrhage, anticoagulants
    should not be administered, antiplatelet agents
    should be stopped
  • Hypertension should be carefully controlled

66
Q19
  • Compared with open repair, endovascular repair of
    a 6.5-cm infrarenal abdominal aortic aneurysm is
    associated with
  • reduced 30-day morbidity and mortality
  • longer recovery times due to persistent endoleaks
  • lower incidence of colon ischemia
  • fewer re-interventions
  • lower treatment costs

67
Q19
  • Compared with open repair, endovascular repair of
    a 6.5-cm infrarenal abdominal aortic aneurysm is
    associated with
  • reduced 30-day morbidity and mortality
  • longer recovery times due to persistent endoleaks
  • lower incidence of colon ischemia
  • fewer re-interventions
  • lower treatment costs

68
Q19
  • Three randomized studies, the EVAR, DREAM and
    OVER trials, compared open versus endovascular
    repair of AAA
  • EVAR significantly lower morbidity and mortality
    at 30 days compared with open repair
  • EVAR (EVAR DREAM trials) higher number of
    re-interventions to treat graft thromosis or
    endoleaks
  • this did not affect the overall recovery rate,
    faster in the endograft group
  • OVER same reinterventions (hernias, bowel
    obstructions, wound complications)
  • Ischemic complications - 700 endovascular
    aneurysm repairs, the incidence of colon ischemia
    was similar to that after open repair. However,
    small bowel ischemia occurred much more commonly
    after endografts, and this complication was
    associated with high mortality
  • Newer studies show risk of colon ischemia lower
    with EVAR (4 vs. 1.4)
  • high cost of endografts one of main disadvantages
    of EVAR
  • overall higher cost of EVAR compared with open
  • additional costs of ongoing surveillance to
    detect graft complications add significantly

69
Q19
EVAR
DREAM
OVER
70
Q19
DREAM
DREAM (6yr f/u)
71
Q20
  • A 42-year-old woman presents with a recurrent
    stasis ulcer on the medial ankle. Venous duplex
    ultrasonography demonstrates complete valvular
    incompetence of the ipsilateral saphenous vein.
    The deep venous system is patent, and the valves
    are competent at all levels. The ulcer heals
    after 6 weeks of compression therapy.
  • The best long-term management option is
  • continued compression therapy with a fitted
    stocking
  • ligation of the saphenofemoral junction and
    saphenous vein stripping
  • subfascial ligation of perforating veins
  • excision of ulcer scar and split-thickness skin
    graft
  • axillary vein valve transfer

72
Q20
  • A 42-year-old woman presents with a recurrent
    stasis ulcer on the medial ankle. Venous duplex
    ultrasonography demonstrates complete valvular
    incompetence of the ipsilateral saphenous vein.
    The deep venous system is patent, and the valves
    are competent at all levels. The ulcer heals
    after 6 weeks of compression therapy.
  • The best long-term management option is
  • continued compression therapy with a fitted
    stocking
  • ligation of the saphenofemoral junction and
    saphenous vein stripping
  • subfascial ligation of perforating veins
  • excision of ulcer scar and split-thickness skin
    graft
  • axillary vein valve transfer

73
Q20
  • venous stasis ulcers 1 of the adult population,
    1/3 unhealed
  • prolonged venous hypertension from valvular
    insufficiency in the saphenous venous system, the
    deep venous system, or both
  • Subfascial ligation - valvular incompetence of
    the deep or perforating veins
  • Ligation of the saphenofemoral junction has been
    associated with ulcer healing, local anesthesia.
  • saphenous vein stripping is unnecessary to
    achieve initial ulcer healing, long-term
    recurrence of venous insufficiency is more likely
    if the saphenofemoral junction is ligated without
    stripping the vein
  • Endoluminal saphenous vein ablation using laser
    or radiofrequency techniques may be an equally
    good option, but long-term results are not yet
    known
  • Transfer of an axillary vein segment containing a
    competent valve - deep venous insufficiency

74
Q21
  • A 53-year-old man presents with a 2-day history
    of pain and swelling in the left leg and thigh.
    Magnetic resonance venography confirms thrombotic
    occlusion of the left common and external iliac
    veins. He is otherwise in good health and has no
    contraindications to anticoagulation.
  • This patient should receive
  • unfractionated heparin only
  • low molecular weight heparin
  • direct thrombin inhibitor
  • catheter-directed thrombolysis
  • systemic thrombolysis

75
Q21
  • A 53-year-old man presents with a 2-day history
    of pain and swelling in the left leg and thigh.
    Magnetic resonance venography confirms thrombotic
    occlusion of the left common and external iliac
    veins. He is otherwise in good health and has no
    contraindications to anticoagulation.
  • This patient should receive
  • unfractionated heparin only
  • low molecular weight heparin
  • direct thrombin inhibitor
  • catheter-directed thrombolysis
  • systemic thrombolysis

76
Q21
  • Conventional therapy DVT systemic heparin
    followed by oral anticoagulation for 3 to 6
    months
  • effective in reducing the risk of pulmonary
    embolus (PE) and recurrent DVT
  • iliofemoral DVT at risk for postthrombotic
    syndrome
  • incomplete venous recanalization and loss of
    normal venous valvular function
  • Surgical thrombectomy often incomplete, and early
    recurrence of the thrombosis commonplace
  • rarely performed except in highly symptomatic
    patients due to phlegmasia
  • Catheter-directed lytic therapy - introduce the
    lytic agent directly into the clot (place
    retrievable IVC filter)
  • fewer bleeding complications compared with
    systemic lysis
  • Multicenter trials overall success rate in over
    80 of treated patients, with a major bleeding
    rate of 11 and a PE rate of 1
  • New mechanical endovascular devices have improved
    the speed and success rate of clot dissolution
  • Once thrombus has been cleared, oral
    anticoagulation 6 months
  • health-related quality of life better with lytic
    therapy - better overall physical functioning,
    less health distress, and fewer postthrombotic
    symptoms

77
Q22
  • A 32-year-old man presents with chronic left leg
    pain and edema. Duplex ultrasonography
    demonstrates continuous flow in the external
    iliac vein that is suggestive of proximal vein
    obstruction. Venography demonstrates a stenosis
    of the left common iliac vein in the area
    underlying the right common iliac artery.
  • The most appropriate treatment would be
  • immediate administration of heparin, followed by
    long-term anticoagulation
  • systemic administration of a lytic agent
  • catheter-based lytic therapy
  • placement of a self-expanding stent
  • surgical resection of the obstructing lesion

78
Q22
  • A 32-year-old man presents with chronic left leg
    pain and edema. Duplex ultrasonography
    demonstrates continuous flow in the external
    iliac vein that is suggestive of proximal vein
    obstruction. Venography demonstrates a stenosis
    of the left common iliac vein in the area
    underlying the right common iliac artery.
  • The most appropriate treatment would be
  • immediate administration of heparin, followed by
    long-term anticoagulation
  • systemic administration of a lytic agent
  • catheter-based lytic therapy
  • placement of a self-expanding stent
  • surgical resection of the obstructing lesion

79
Q22
  • In humans, the left common iliac vein is crossed
    anteriorly by the right common iliac artery
  • chronic compression of the vein by the artery
  • May-Thurner syndrome
  • most cases asymptomatic
  • risk factor for deep venous thrombosis (DVT)
  • Patients may present with pain and edema due to
    venous hypertension before the onset of DVT
  • Endovascular therapy with metallic stents is
    effective in relieving the external compression,
    with 2-year primary patency rates gt 90
  • catheter-directed lysis to treat venous
    thrombosis before stent placement

80
Q23
  • Endovascular repair of an abdominal aortic
    aneurysm has improved outcome over open repair in
    all of the following EXCEPT
  • graft complications
  • mortality
  • cardiac complications
  • pulmonary complications
  • length of hospital stay

81
Q23
  • Endovascular repair of an abdominal aortic
    aneurysm has improved outcome over open repair in
    all of the following EXCEPT
  • graft complications
  • mortality
  • cardiac complications
  • pulmonary complications
  • length of hospital stay

82
Q24
  • Which of the following statements about
    arteriovenous fistulas (AVFs) for hemodialysis
    access in patients with end-stage renal disease
    is TRUE?
  • AVFs should be placed immediately after patients
    have started dialysis
  • Over 50 of such patients are being dialyzed
    through AVFs
  • The radiocephalic fistula can be done in over 50
    of all patients
  • If an AVF fails to mature properly, secondary
    operations are rarely successful
  • For a patient with small vessels, a prosthetic
    graft will provide a higher patency rate than a
    radiocephalic fistula

83
Q24
  • Which of the following statements about
    arteriovenous fistulas (AVFs) for hemodialysis
    access in patients with end-stage renal disease
    is TRUE?
  • AVFs should be placed immediately after patients
    have started dialysis
  • Over 50 of such patients are being dialyzed
    through AVFs
  • The radiocephalic fistula can be done in over 50
    of all patients
  • If an AVF fails to mature properly, secondary
    operations are rarely successful
  • For a patient with small vessels, a prosthetic
    graft will provide a higher patency rate than a
    radiocephalic fistula

84
Q24
  • In any given year, some 240,000 patients with
    end-stage renal disease are being treated with
    maintenance hemodialysis
  • Venous catheters last only a few months at most
  • arteriovenous grafts may last a year or two
  • arteriovenous fistula (AVF) may last for several
    years, the best method of access
  • Center for Medicare and Medicaid Services (CMS)
    has announced a Fistula First movement, with the
    objective of placing AVFs in dialysis patients
    before they begin receiving dialysis. It takes 3
    to 4 months for a fistula to mature, and often
    longer, especially in diabetics, and a revision
    may be necessary
  • Achieving a higher rate of first-use AVF requires
    that patients be identified 6 to 12 months prior
  • The radiocephalic arteriovenous fistula
    (Brescia-Cimino shunt) best
  • More than half of patients cannot have because
    vessels too small or because cephalic vein
    occluded
  • forearm loop graft with prosthetic material,
    which has a lower patency rate than a
    Brescia-Cimino shunt, superior in patients with
    small vessels
  • In prosthetic grafts, just as with nongraft
    fistulas, re-operation will often salvage a
    clotted fistula

85
Q25
  • A 32-year-old man presents with swelling of the
    forearm, as shown. He has intermittent tingling
    in the ring and small fingers. He is in moderate
    discomfort. Two-point discrimination is slightly
    diminished in the ring and small fingers. Hand
    compartments are soft. X-rays show soft tissue
    swelling and no obvious fracture. Compartment
    pressures are 20 mm Hg for the volar forearm
    compartment, 16 mm Hg for the dorsal compartment,
    and 18 mm Hg for the mobile wad.
  • The next step should be
  • analgesics and antibiotics with discharge home
  • hospital admission, serial examinations
  • hospital admission, hyperbaric oxygen
  • carpal tunnel release
  • volar and dorsal forearm fasciotomy

86
Q25
  • A 32-year-old man presents with swelling of the
    forearm, as shown. He has intermittent tingling
    in the ring and small fingers. He is in moderate
    discomfort. Two-point discrimination is slightly
    diminished in the ring and small fingers. Hand
    compartments are soft. X-rays show soft tissue
    swelling and no obvious fracture. Compartment
    pressures are 20 mm Hg for the volar forearm
    compartment, 16 mm Hg for the dorsal compartment,
    and 18 mm Hg for the mobile wad.
  • The next step should be
  • analgesics and antibiotics with discharge home
  • hospital admission, serial examinations
  • hospital admission, hyperbaric oxygen
  • carpal tunnel release
  • volar and dorsal forearm fasciotomy

87
Q25
  • gunshot wound to the forearm
  • risk for compartment syndrome
  • may also have injury to the ulnar nerve related
    to direct injury or compression from local edema
    or blast injury
  • documentation of presenting and subsequent
    neurologic examinations
  • Sensory deficits (paresthesias or numbness)
    usually precede motor dysfunction
  • Muscles and nerves are especially vulnerable to
    ischemia and incur irreversible damage if
    increased pressures are maintained
  • compartment syndrome (pain out of proportion to
    the injury, pain with passive extension of the
    compartment muscles, swollen tense compartments)
  • confirmed by intracompartmental tissue fluid
    pressures gt 30 mm Hg
  • forearm has three major compartments
  • anterior (volar)
  • posterior (dorsal)
  • mobile wad (includes brachioradialis, extensor
    carpi radialis longus, and extensor carpi
    radialis brevis)
  • The carpal canal, although open at both ends, is
    a physiologic compartment and should be released
    when median nerve compression is identified.
  • Hyperbaric oxygen is not an acceptable primary
    treatment for compartment syndrome

88
Q25
89
Q27
  • A 57-year-old man has the angiogram shown. Which
    of the following statements is TRUE?
  • Anticoagulation is indicated
  • Limb loss is likely without revascularization
  • He is likely to complain of pain in his foot with
    walking
  • He has a decreased life expectancy
  • Antiplatelet therapy has no role in the medical
    management of this patient

90
Q27
  • A 57-year-old man has the angiogram shown. Which
    of the following statements is TRUE?
  • Anticoagulation is indicated
  • Limb loss is likely without revascularization
  • He is likely to complain of pain in his foot with
    walking
  • He has a decreased life expectancy
  • Antiplatelet therapy has no role in the medical
    management of this patient

91
Q27
  • occlusion of the superficial femoral artery
  • peripheral arterial disease (PAD)
  • Claudication - intermittent nature with
    occurrence during exercise and abatement with
    rest
  • calf, thigh, and buttock
  • Symptoms occur distal to the stenosis or
    occlusion as oxygen demand increases with
    exercise but cannot be supplied
  • Foot pain with ambulation is not a typical
    presentation because the amount of muscle in the
    calf is far greater and usually produces symptoms
    first
  • Anticoagulation will not improve walking distance
    and is not indicated
  • Revascularization is only required in one third
    of patients with claudication and limb loss is
    relatively rare
  • More ominous, however, is the association of
    claudication and peripheral arterial disease with
    stroke and myocardial infarction
  • Patients with symptomatic peripheral arterial
    disease have twice the risk of mortality from
    these atherothrombotic disease processes
  • Antiplatelet agents are indicated in these
    patients to reduce cardiovascular mortality and
    morbidity

92
Q28
  • Which of the following statements about the
    findings shown in this computed tomographic (CT)
    scan is TRUE?
  • This is the most common site of aneurysmal
    disease
  • Successful surgical repair eliminates any further
    enlargement
  • Rupture is more likely to occur than thrombosis
  • Embolization from the aneurysm is a continuous
    risk
  • There is no role for thrombolytic therapy

93
Q28
  • Which of the following statements about the
    findings shown in this computed tomographic (CT)
    scan is TRUE?
  • This is the most common site of aneurysmal
    disease
  • Successful surgical repair eliminates any further
    enlargement
  • Rupture is more likely to occur than thrombosis
  • Embolization from the aneurysm is a continuous
    risk
  • There is no role for thrombolytic therapy

94
Q28
  • aneurysms of both popliteal arteries (the left is
    larger than the right)
  • Abdominal aortic aneurysms (AAA) occur more
    frequently, but aneurysms of the popliteal artery
    are the most frequently occurring peripheral
    arterial aneurysms, accounting for more than 70
  • Unlike AAAs, rupture of an aneurysm in this
    location is extremely rare
  • Most patients present with symptoms of
    emoblization (blue toes) or acute limb ischemia
  • Many authors recommend surgical intervention when
    the aneurysm is diagnosed
  • The risk of developing symptoms is 14 per year
    and includes the risk of complete thrombosis.
    Limb loss in this setting occurs in approximately
    30
  • Planning revascularization is often complicated
    by the embolization and thrombosis of normal
    caliber distal vessels that would have been
    suitable for bypass
  • Thombolytic therapy in this setting to identify
    patent distal vessels, improve small vessel flow,
    and improve subsequent bypass patency
  • Surgical intervention requires ligation of the
    aneurysm and reconstruction with autogenous
    conduit whenever possible
  • 80 patency at 5 years is commonly reported
  • endovascular exclusion of the aneurysm with
    in-line reconstruction with a covered stent graft
  • Even with ligation of the proximal and distal
    vessel around the aneurysm, patency of the
    geniculates resulting in continued aneurysm
    growth has been reported
  • This complication is best treated with
    exploration from a posterior incision with
    ligation of the patent vessels from within the
    aneurysm sac

95
Q29
  • Which of the following statements about the
    lesion shown is TRUE?
  • If the patient is otherwise healthy and
    asymptomatic, this lesion should be managed
    medically
  • The patient is at increased risk of stroke, heart
    attack, and death with or without operative
    intervention
  • Endovascular treatment is associated with
    improved outcome when compared with operation
  • Successful operative or endovascular intervention
    eliminates the need for continued medical therapy
  • If the patient has already had a stroke,
    operative intervention is not indicated

96
Q29
  • Which of the following statements about the
    lesion shown is TRUE?
  • If the patient is otherwise healthy and
    asymptomatic, this lesion should be managed
    medically
  • The patient is at increased risk of stroke, heart
    attack, and death with or without operative
    intervention
  • Endovascular treatment is associated with
    improved outcome when compared with operation
  • Successful operative or endovascular intervention
    eliminates the need for continued medical therapy
  • If the patient has already had a stroke,
    operative intervention is not indicated

97
Q29
  • severe stenosis of the right internal and
    external carotid artery
  • patients with atherosclerotic disease of the
    internal carotid artery are at increased risk of
    coronary artery disease, heart attack, stroke,
    and death, regardless of the therapy offered

98
Q31
  • A 75-year-old man who had an abdominal aortic
    aneurysm repair 5 years previously with an
    aorto-bifemoral graft presents with malaise and
    generalized abdominal pain. On physical
    examination, his abdomen is diffusely tender and
    he is normotensive. Pertinent data include a
    hemoglobin of 12 g/dL and WBC count of
    19,800/mm3. The computed tomographic (CT) scan
    shown is obtained.
  • Which of the following statements about his
    diagnosis and management is TRUE?
  • Treatment will require ostomy formation
  • A negative upper endoscopy eliminates the need
    for operation
  • Graft excision and extra-anatomic reconstruction
    should be performed immediately
  • Systemic antibiotics should be started
    immediately
  • Percutaneous drainage is adequate therapy

99
Q31
  • A 75-year-old man who had an abdominal aortic
    aneurysm repair 5 years previously with an
    aorto-bifemoral graft presents with malaise and
    generalized abdominal pain. On physical
    examination, his abdomen is diffusely tender and
    he is normotensive. Pertinent data include a
    hemoglobin of 12 g/dL and WBC count of
    19,800/mm3. The computed tomographic (CT) scan
    shown is obtained.
  • Which of the following statements about his
    diagnosis and management is TRUE?
  • Treatment will require ostomy formation
  • A negative upper endoscopy eliminates the need
    for operation
  • Graft excision and extra-anatomic reconstruction
    should be performed immediately
  • Systemic antibiotics should be started
    immediately
  • Percutaneous drainage is adequate therapy

100
Q31
  • Prosthetic graft infections most dreaded
    complicatios after aortic reconstruction, 1 to
    6 of cases
  • generalized malaise, fever, leukocytosis with
    melena, and hematemesis if the graft has eroded
    into the adjacent bowe
  • CT findings perigraft air or fluid, soft tissue
    attenuation between the graft and the aortic wall
    after the immediate
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