Peripheral Vascular Disease

1. Define claudication:

Cramping pain in specific muscle groups that occurs when blood flow is
inadequate for meeting the demands of exercise.

2. Describe ulcers resulting from arterial insufficiency:

Involve the toes or plantar surface of the foot and are painful.

3. Describe venous ulcers:

Less painful, typically occur near the malleoli.

4. What does tissue necrosis in PVD signify?

Multilevel disease of the distal arterial tree

Chronic proximal occlusion alone is associated with the development of

collateral circulation, which is normally adequate for preventing necrosis and
gangrene.

5. Most common site of atherosclerotic occlusion in the lower extremities =

Distal superficial femoral artery.

The occlusion occurs in the adductor canal proximal to the popliteal fossa
and is related to the anatomic relationship of the artery to the adductor
magnus tendon at this site.

6. In PVD, impotence is caused by:

Occlusion of the hypogastric (internal iliac) artery, which reduces blood flow
through the internal pudendal artery and corpora cavernosa.
7. What is Leriche syndrome?

Intermittend claudication of the thighs/buttocks, impotence, and diminished

or absent femoral pulses indicative of aortoiliac atherosclerotic occlusive
disease.

8. What is "blue toe syndrome"?

Emboli from atherosclerotic plaque in the aortoiliac vessels that may cause
distal tissue necrosis even in the absence of occluding lesions.

9. Principal cause of death in patients with aortoiliac atherosclerotic occlusive

disease is:

Coronary artery disease.

10. % per year of patients with intermittent claudication that progresses to gangrene:

2-3%

11. What vessels does Raynaud syndrome affect?

Vasospasm of the small arteries and arterioles of the most distal portions of
the extremities (i.e.: the hands, fingers, feet, and toes)

12. Regarding femoropopliteal bypass, patency rates are higher when performed for
claudication or limb salvage?

Claudication because of the extent of the underlying pathologic process.

13. Name the classic signs of acute arterial occlusion (the five P's):
o Pain
o Pallor
o absence of Pulse
o Paralysis
o Paresthesia
14. What are the common causes of acute arterial occlusion?
o Embolism
o Thrombosis
o Trauma
15. Initial treatment of acute arterial embolus to the lower extremity with limb
threatening ischemia =
 IV 5000unit heparin bolus followed by continuous-drip administration

16. Gold standard for assessing completeness of thromboembolectomy =

o Restoration of distal pulses or Doppler signals
o Intraoperative arteriography when necessary
17. Most arterial emboli originate from:

The left atrium

18. Arterial emboli of cardiac origin most frequently produce occlusion of:

The common femoral artery.

19. Most common symptom of thoracic outlet syndrome =

Pain/paresthesia in the C8-T1 nerve distribution

20. What is Buerger disease?

inflammatory thrombosis of the small & medium-sized vessels of the upper

and lower extremities

aka Thromboangiitis obliterans

associated with tobacco use

21. Frostbite treatment:

Rapid rewarming with warm water

22. Pt most commonly affected by popliteal artery entrapment syndrome =

men before age 40

23. What is post-thrombotic syndrome?

How often does it occur?

Valvular incompetence in deep veins below the knee and perforating veins
following a DVT.

Occurs in up to 60% of patients following a DVT

24. When is it best to use TPA or Urokinase in the treatment of DVT?

Most effective when given to patients with DVT of less than 5-7 days
duration

Best results in patients who have had symptoms for less than 48hrs.

Contraindicated within 4 weeks of major operations or injury.

25. What is phlegmasia cerula dolens?

Early thrombus removal can prevent progression to venous gangrene

26. Describe the Trendelenberg test for diagnosing venous insufficiency:

Two-part test used to delineate the competence of the superficial and

perforating veins.

While supine, the patient elevates the legs until the superficial veins empty

o Part 1 - saphenofemoral junction is occluded digitally and the patient

is asked to stand, superficial veins are observed for 30 seconds
o Positive Test = rapid filling, indicates incompetence of deep and
perforating veins

o Part 2 - saphenofemoral occlusion released while the veins are kept

under observation
o Positive Test = rapid retrograde filling, indicates incompetence of the
valves of the superficial system
27. Describe the three types of primary lymphedema:

1. Congenital lymphedema (Milroy Disease if + family history)

2. Lymphedema praecox (Meige disease if + family history) - onset < 35yo,

most common

3. Lymphedema tartda - onset >35yo

28. Acquired peripheral arteriovenous fistula treatment:

 Percutaneous techniques such as detachable balloons and embolization.

29. What is Paget-von Schroetter Syndrome?

aka: axillary-subclavian vein thrombosis

Spontaneous, typically occurs in males following upper extremity exertion

30. Paget-von Schroetter Syndrome diagnosis:

Gold standard = venography

31. Indications for Inferior Vena Cava filter =

o Pts with contraindication to anticoagulation
o Recurrent PE/DVT despite anticoagulation
32. Paget-von Schroetter Syndrome treatment:

Catheter-directed thrombylysis and resection of first rib if patency is restored

and venous narrowing demonstrated

33. Heparin-Induced Thrombocytopenia treatment:

Direct thrombin inhibitors such as Lepirudin & Argatroban

o Lepirudin depends on renal clearance

o Argatroban depends on hepatic functional status
34. Lymphedema diagnosis:

Direct contrast-enhanced lymphangiography

35. Change in ABI in response to exercise for healthy vs. diseased patient:
o Healthy - ABI goes up
o Diseased - ABI goes down

1. Most common congenital hypercoagulaboe disorder

Leiden factor (resistance to protein C)

2. Most common aquired hypercoagulability disorder

 Smoking

3. Macrophages that have absorbed fat and lipids in the blood vessel wall

Foam cells

4. Exposure of collagen in vessel wall and eventual throbus formation

Intimal disruption

5. Atherosclerosis: layer that it effects

Intima

6. Hypertension: layer that it effects

Media

7. 3rd most common cause of death in US

stroke

8. amount of blood supply provided to brain by carotids

85%

9. flow pattern of a normal internal carotid artery

continuous forward flow

10. normal flow pattern of the external carotid artery

triphasic flow

11. 1st branch of external carotid artery

superior thyroid

12. vessels that provide communication between internal carotid and external carotid
(2)

ophthalmic artery, internal maxillary artery

13. most commonly diseased intracranial artery

 middle cerebral artery

14. most common source of cerebral ischemic events

arterial embolization from ICA

15. symptoms associated with anterior cerebral artery events

mental status changes, release, slowing

16. symptoms associated with middle cerebral artery events

contralateral motor and speech, face droop

17. occlusion of ophthalmic branch of ICA causing transient visual effects

amaurosis fugax

18. candidates for CEA

>= 70% stenosis and symptoms

19. stump pressures requiring shunt during CEA

>50

20. most commonly injured cranial nerve during CEA

vagus

21. complications of CEA

stroke, pseudoaneurysm, hypertension, MI

22. signs of vertebrobasilar insufficiency (7)

diplopia, dysarthria, vertigo, tinnitus, drop attack, incoordination, binocular

vision loss

23. tumor presenting as painless neck mass near bifurcation of carotid

carotid body tumor

24. symptoms of ascending aortic aneurysm

 aortic insufficiency, back pain, voice changes, dyspnea, dysphagia

25. indications for repair of ascending aortic aneurysm (4)

>=7cm, >=6cm with Marfan�s, diameter 2X normal, rapid increase in size

26. aneurysm classification for those with any ascending aortic involvement

Class A

27. Aneurysm classification for those with descending involvement only

Class B

28. DeBakey classification for aneurysms with ascending an descending involvement

Type I

29. DeBakey classification for aneurysms with ascending involvement only

Type II

30. DeBakey classification for aneurysms with descending involvement only

Type III

31. Layer of blood vessel where dissection occurs

Media

32. Ascending aortic dissections that need operative repair

ALL of them

33. Descending aortic dissections that need operative repair

Visceral, renal or leg ischemia, persistent pain, large size

34. Artery perfusing spinal cord, whose injury causes paraplegia if occluded during
repair

Artery of Adamkiewicz

35. Symptoms of AAA

 Rupture, distal embolixation, compression of adjacent organs

36. Rupture risk of AAA 5cm

15-20% 5-year

37. rupture risk of AAA >8cm

100% 5-year

38. indications for AAA repair (3)

symptomatic, >5cm, growth >0.5cm/yr

39. situations when IMA should be reimplanted during AAA repair

backpressure <40mmHg, previous colon surgery, SMA stenosis, inadequate

flow to colon

40. bloody diarrhea after AAA: dx?

Ischemic colitis

41. Organisms common in mycotic aneurysms (2)

Salmonella, staph

42. Treatment of mycotic aneurysm

Extraanatomic bypass, resection of infected portion of aorta

43. Organisms common in aortic graft infections (2)

Staph, E.coli

44. Treatment of aortic graft infection

Resect graft, bypass through noncontaminated field

45. Herald bleed with hematemesis, then blood per rectum ~6mos after AAA

Aortoenteric fistula

46. Treatment of aortoenteric fistula

 Axillary bifem, graft resection

47. Endoleak that is proximal, distal, or through the stent

Type I endoleak

48. Endoleak that is persistent blood flow through lumbars or IMA

Type II endoleak

49. Nerve and vessel in anterior compartment of leg

Deep peroneal nerve, anterior tibial artery

50. Nerve in lateral compartment of the leg

Superficial peroneal nerve

51. Nerve and 2 vessels in the deep posterior compartment of the leg

Tibial nerve, posterior tibial and peroneal arteries

52. Nerve in superficial posterior compartment of the leg

Sural nerve

53. Treatment of homocysteinuria

Folate, B6, B12

54. Yearly risk of gangrene and amputation with claudication

2%/year and 1%/year

55. symptoms of aortoiliac occlusion

buttock pain

56. symptoms of external iliac occlusion

midthigh claudication

57. symptoms of common femoral or proximal superficial femoral artery occlusion

 calf claudication

58. symptoms of distal SFA or popliteal disease

foot claudication

59. syndrome with a lesion at or above aortic bifurcation, causing lack of femoral
pulse, buttock/thigh claudication, impotence

Leriche syndroma

60. Most common atherosclerotic occlusion in lower extremities

Hunter�s canal (exit of SFA)

61. ABI where claudication starts

<0.9

62. ABI where rest pain starts

<0.6

63. ABI where ulcers start (usually on toes)

<0.5

64. ABI where gangrene starts

<0.3

65. studies to find significant occlusion and at what level

PVRs (peripheral vascular resistance studies

66. Gold standard for vascular imaging to detect occlusion

Angiogram

67. Surgical indications for PVD (4)

Rest pain, ulceration or gangrene, lifestyle limitation, atheromatous

embolixation
68. Graft material good for aorta and large vessels

Dacron

69. Typeical repair for aortoiliac disease

Aortobifemoral repair

70. 5-year patency of femoropopliteal grafts

75%

71. 5-year patency of femoral-distal grafts

50%

72. complications of reperfusion of ischemic tissue (4)

lactic acidosis, hyperkalemia, myoglobinuria, compartment syndrome

73. tx for patients with heel ulceration to bone

amputation

74. tx for patients with dry gangrene

allow to autoamputate

75. tx for wet gangrene

amputation to remove infected necrotic tissue + antibiotics (surgical

emergency)

76. good lesions for PCTA

common iliac lesions, short segments

77. tx for pseudoaneurysm after arteriography

thrombin injection (u/s guided)

78. most common compartment of leg to get compartment syndrome

anterior
79. pressures requiring fasciotomies

>20-30

80. mild intermittent claudication in med in their 40�s; primary symptom is loss of
pulses with plantarflexion

popliteal entrapment syndrome

81. treatment for popliteal entrapment syndrome

resection of medial head of gastroc

82. intermittent claudication with changes in symptoms with knee flexion and
extension

adventitial cystic disease

83. tx of adventitial cystic disease

vein graft if occluded, resection of cyst

84. 3-year mortality after BKA or AKA

50%

85. % of patients who walk again after BKA

70

86. % of people who walk again after AKA

30%

87. most common cause of acute arterial emboli

atrial fibrillation

88. most common site of peripheral obstruction from emboli

common femoral artery

89. flaking of atherosclerotic emboli off abdominal aorta or branches; good distal
pulses
 blue toe syndrome

90. treatment of acute arterial thrombosis

heparin, OR for thrombectomy (if limb threatened), angio for thrombolytics (if
limb not threatened)

91. treatment of thrombosed PTFE graft

thrombolytics, anticoagulation

92. source of most renal emboli

heart

93. most common location for renal atherosclerosis

Left proximal 1/3, more in men

94. Most common location for renal fibromuscular dysplasia

Right distal 1/3, more in women

95. Diagnostic study for renal artery stenosis

Renal angiogram

96. Tx of renal artery stenosis

PTA with stent

97. Indications for nephrectomy with renal HTN

Atrophic kidney <6cm with persistently elevated rennin level

98. Most common site of upper extremity stenosis

Subclavian

99. Proximal subclavian artery stenosis resulting in reversal of flow through ipsilateral
vertebral artery into subclavian

Subclavian steal syndrome

100. Treatment of subclavian steal syndrome

Carotid to subclavian bypass or PTA

101. Normal position of subclavian vein in relation to ribs, scalene and clavicle

Vein passes over 1st rib anterior to anterior scalene, then behind clavicle

102. Normal position of subclavian artery and brachial plexus in relation to ribs,
scalene and clavicle

Artery passes over 1st rib posterior to anterior scalene and anterior to middle
scalene

103. Test looking at radial pulse with head turned to the ipsilateral side

Adson�s test

104. Location of ulnar nerve on brachial plexus (superior, middle, or inferior)

Inferior portion

105. Location of radial nerve on brachial plexus (superior, middle or inferior)

Superior portion

106. Treatment of thoracic outlet syndrome

Cervical rib resection, division of anterior scalenes and middle scalenes.

Possible 1st rib resection

107. Effort induced thrombosis of subclavian vein

Paget von Schrotter disease

108. CT findings that suggest intestinal ischemia

Bowel wall thickening, intramural gas, portal venous air, vascular occlusion

109. Most common cause of visceral ischemia

Acute embolic occlusion (50%)

110. Causes of visceral ischemia (4)

 Embolus, thrombotic occlusion, low flow state, venous thrombosis

111. Most common source of SMA embolus

Heart

112. Treatment of SMA embolus

Resuscitation, antibiotics, embolectomy, resection, heparin

113. Treatment of SMA thrombus

Thrombectomy, SMA bypass, resection, heparin

114. Treatment of mesenteric vein thrombosis

Heparin, thrombolytics, thrombectomy if diagnosed early

115. Nonocclusive mesenteric ischemia: definition

low cardiac output state to visceral vessels caused by spasm, low-flow states, or
hypovolemia

116. most vulnerable areas for nonocclusive mesenteric ischemia (2)

Griffiths and Sudak�s points

117. Celiac compression causing chronic abdominal pain, weight loss, diarrhea

Median arcuate ligament syndrome

118. Visceral angina 30 min after meals, weight loss due to food fear

Chronic mesenteric ischemia

119. Most common complication of aneurysms above inguinal ligament

Rupture

120. Most common complication of aneurysms below inguinal ligament

Thrombus/emboli

121. Most common visceral aneurysm in women

 Splenic

122. Indications for splenic artery aneurysm repair

Symptomatic, pregnancy, women of childbearing age

123. Treatment of visceral, iliac and femoral aneurysm

Exclusion and bypass graft

124. Indications for surgery for iliac aneurysm

Symptomatic, >3cm, mycotic

125. Indications for surgery for femoral aneurysm

Symptomatic, >2.5cm, mycotic

126. Most common peripheral aneurysm

Popliteal

127. % of people with popliteal aneurysm who have another aneurysm

50%

128. surgical indications for popliteal aneurysm

symptomatic, >2cm, mycotic

129. collection of blood in continuity with arterial system but unenclosed by all
3 layers of arterial wall

femoral pseudoaneurysm

130. disease with string of beads appearance on angiogram

fibromuscular dysplasia

131. gangrene of fingers>toes, severe rest pain with bilateral ulceration

Buerger�s disease

132. Type I collagen defect causing retinal detachment, aortic root dilatiation
 Marfan�s syndrome

133. Collagen defect resulting in easy bruising, hypermobile joints, arterial

rupture

Ehlers-Danlos syndrome

134. Large artery arteritis causing fever, arthralgia, visual changes, myalgia,
anorexia (common in women >55)

Temporal arteritis

135. Large artery arteritis causing fever, arthralgia, myalgia, and anorexia
(common in women <35)

Takayasu�s arteritis

136. Treatment of large vessel arteritis

Steroids, bypass

137. Medium vessel arteritis (2)

Polyarteritis nodosa, kawasaki�s disease

138. Small vessel arteritis, often secondary to drug/tumor antigens

Hypersensitivity angitis

139. Vasculitis of young women with subsequent vasoconstriction and cyanotic

extremities

Raynaud�s disease

140. Most common failure of AV grafts for dialysis

Venous obstruction secondary to intimal hyperplasia

141. Indications for surgical treatment of varicose veins

Symptomatic, recurrent ulcers, severe varicosities

142. Disease secondary to venous incompetence

 Venous ulcers

143. Treatment of venous ulcers

Unna boot, ligate perforators, vein stripping

144. Trendelenburg test

Test of venous insufficiency: elevate leg, occlude greater saphenous, then lower
leg to see how rapid the refilling of the vein is

145. Disease with achy, swollen legs and night cramps, as well as brawny edema

Venous insufficiency

146. Nonbacterial inflammation of superficial veins

Superficial thrombophlebitis

147. Bacterial infection of superficial veins

Suppurative thrombophletibis

148. Self-limiting thrombophlebitis of the breast

Mondor�s disease

149. Methods by which SCD�s prevent clots (3)

Decreased venous stasis, increased ATIII and tPA, increased fibrinolysis

150. Leg more commonly affected by DVT

Left (longer iliac vein compressed by iliac artery)

151. Virchows triad

Venous stasis, hypercoaguability, venous wall injury

152. Tenderness, pallor and edema of lower extremity

Phlegmasia alba dolens

153. Tenderness, cyanosis and massive edema of lower extremity

 Phlegmasia cerulea dolens

154. Source of PE when a DVT filter is in place (3)

Ovarian veins, IVC superior to filter, upper extremities

155. Treatment of 1st DVT

Coumadin 6 months

156. Treatment of 2nd DVT

Coumadin 12 months

157. Treatment of 3rd DVT or PE

Lifetime Coumadin

158. ABG changes of PE

Dec pO2, dec pCO2, respiratory alkalosis

159. Tissue types with no lymphatics (6)

Bone, muscle, tendon, cartilage, brain, cornea

160. Lymphangiosarcoma associated with breast axillary dissection

Stewart-Treves syndrome

161. Dilation of preexisting lymphatic channels

Lymphangiectasia