Describe the risk factors associated with atherosclerosis: -
O O O O O O O
ANSWER Smoking, diabetes, hyperlipidemia, obesity, HTN, sedentary lifestyle
O O O O O O O O
Arterial ulcers vs venous ulcers - ANSWER Arterial ulcers—
O O O O O O O O
painful and usually occur on toes or foot
O O O O O O O
Venous ulcers—commonly broad-based, shallow at medial malleolus
O O O O O O
Claudication— - O
ANSWER cramping ischemic muscle pain with exertion that occurs distal to arterial stenosis, ass
O O O O O O O O O O O O O O
ociated with 1% risk of limb loss and 5% mortality.
O O O O O O O O O
Rest pain— -O O
ANSWER due to ischemia, arises without exertion and classically wakes patients from sleep (oft
O O O O O O O O O O O O O O
en over distal metatarsals). The pain may resolve with standing or placing foot over side of bed (
O O O O O O O O O O O O O O O O O
dependent position, gravity). >50% patients eventually require amputation.
O O O O O O O
Dry gangrene— - ANSWER necrotic "mummified" tissue without signs of infection—
O O O O O O O O O O
not a surgical emergency
O O O
Wet gangrene— - ANSWER necrotic tissue indicative of active infectious process—
O O O O O O O O O O
requires aggressive debridement or amputation to avoid sepsis
O O O O O O O
How are ankle brachial index/digital brachial index (ABIs/DBIs) and segmental pressures measur
O O O O O O O O O O O
ed? Pulse volume recordings (PVRs)? What is their significance? -
O O O O O O O O O
ANSWER Normal ABI at rest: 1.0 to 1.2, mild arterial insufficiency: 0.7 to 0.9, claudication: 0.5 to
O O O O O O O O O O O O O O O O O
0.7, rest pain and ultimately tissue necrosis: <0.4 (falsely elevated ABIs may be seen in diabetic
O O O O O O O O O O O O O O O O O
patients or those with chronic renal disease due to extensive vascular calcification).
O O O O O O O O O O O
,PVRs analyze the waveforms at sequential sites along patient's leg—
O O O O O O O O O
triphasic or biphasic waveforms, indicates more perfusion than monophasic.
O O O O O O O O
What is the half-life of heparin? Intraoperative therapeutic dosing? How is it reversed? -
O O O O O O O O O O O O O
OANSWER Half- O
life is 60 to 90 minutes. Intraoperative dosing is 70 to 100 units/kg (activating clotting time of 25
O O O O O O O O O O O O O O O O O
0 to 350 seconds if measured). Protamine sulfate: 1 mg/100 units of heparin.
O O O O O O O O O O O O
What are the 5- O O O
year patencies of common and external iliac percutaneous transluminal angioplasty (PTA) witho
O O O O O O O O O O O
ut stenting? - ANSWER Common iliac: 70% to 80%
O O O O O O O O
External iliac: 50% to 60% O O O O
What are the classic signs/symptoms of acute arterial occlusion? In what order do they present?
O O O O O O O O O O O O O O
- ANSWER The "6 P's" include: Paresthesias, Pain, Pallor, Poikilothermia, Pulselessness, Paralysis
O O O O O O O O O O O O
What percentage of emboli originate in the heart? First and second most common causes? -
O O O O O O O O O O O O O O
ANSWER 80% of peripheral emboli are due to cardiac etiology (First—
O O O O O O O O O O O
atrial fibrillation, Second—acute MI)
O O O
At what anatomic sites do atherosclerotic lesions most commonly occlude? -
O O O O O O O O O O
ANSWER Atherosclerosis forms at branch points such as carotid bifurcation, bends, and tethere
O O O O O O O O O O O O O
d segments such as superficial femoral artery as it passes through Hunter canal Emboli lodge at
O O O O O O O O O O O O O O O O
arterial bifurcation—that is, femoral bifurcation, brachial bifurcation
O O O O O O
How can a peripheral venous embolus cause occlusion in the peripheral arterial circulation? -
O O O O O O O O O O O O O
OANSWER A "paradoxical embolus" occurs when a peripheral venous thromboembolus crosses in
O O O O O O O O O O O
to the peripheral arterial circulation through a patent foramen ovale in the heart.
O O O O O O O O O O O O
What is the risk of limb loss associated with acute thromboembolic disease? What is the associa
O O O O O O O O O O O O O O O
ted mortality? - ANSWER Risk of limb loss: 8% to 22%
O O O O O O O O O O
, Thromboembolic perioperative mortality: 10% to 17% O O O O O
Name some of the indications to operate for peripheral arterial occlusive disease: -
O O O O O O O O O O O O
OANSWER Tissue necrosis, rest pain, infection, debilitating claudication refractory to nonoperativ
O O O O O O O O O O
e management (Pentoxifylline, Aspirin, Cessation of smoking, Exercise—
O O O O O O O
PACE pneumonic) NOTE—
O O
claudication is not an indication for surgery; it is best treated with supervised exercise training.
O O O O O O O O O O O O O O
What is 5-year patency rate of Fem-Pop vein grafts versus prosthetic grafts - ANSWER 5-
O O O O O O O O O O O O O O
year patency of an above-the-
O O O O
knee vein graft is 75% (no difference between in situ or reverse); prosthetic is 40% to 50%.
O O O O O O O O O O O O O O O O
5-year patency of a below-the-knee vein graft is 65%, prosthetic is 30%.
O O O O O O O O O O O
What do early (<30 day), intermediate, and late (>2 year) bypass graft failures generally represe
O O O O O O O O O O O O O O
nt? - ANSWER Early—Use of small, poor-
O O O O O O
quality vein; anastomosis to inadequate outflow artery or technical error (kink/twist of graft; inc
O O O O O O O O O O O O O
omplete lysis of valves) at the time of surgery Intermediate—
O O O O O O O O O
Intimal hyperplasia at anastomotic sites or valve sites within the graft Late—
O O O O O O O O O O O
Progression of atherosclerotic disease within the inflow or outflow vessels
O O O O O O O O O
Name the 4 calf compartments in order of compartment syndrome probability: -
O O O O O O O O O O O
ANSWER Anterior, lateral, deep posterior, superficial posterior compartment
O O O O O O O O
What is the first sign of compartment syndrome? How long after revascularization is greatest ris
O O O O O O O O O O O O O O
k? - O
ANSWER Numbness of great toe webbing is an early sign of compartment syndrome due to dee
O O O O O O O O O O O O O O O O
p peroneal nerve compression (anterior). Greatest risk occurs 4 to 6 hours after revascularizatio
O O O O O O O O O O O O O
n along with release of intracellular ions/proteins/enzymes from damaged sarcolemma.
O O O O O O O O O
What is the most common iatrogenic injury during anterior compartment fasciotomy? -
O O O O O O O O O O O
ANSWER Injury to the lateral peroneal nerve in the superior aspect of the incision
O O O O O O O O O O O O O O
O O O O O O O
ANSWER Smoking, diabetes, hyperlipidemia, obesity, HTN, sedentary lifestyle
O O O O O O O O
Arterial ulcers vs venous ulcers - ANSWER Arterial ulcers—
O O O O O O O O
painful and usually occur on toes or foot
O O O O O O O
Venous ulcers—commonly broad-based, shallow at medial malleolus
O O O O O O
Claudication— - O
ANSWER cramping ischemic muscle pain with exertion that occurs distal to arterial stenosis, ass
O O O O O O O O O O O O O O
ociated with 1% risk of limb loss and 5% mortality.
O O O O O O O O O
Rest pain— -O O
ANSWER due to ischemia, arises without exertion and classically wakes patients from sleep (oft
O O O O O O O O O O O O O O
en over distal metatarsals). The pain may resolve with standing or placing foot over side of bed (
O O O O O O O O O O O O O O O O O
dependent position, gravity). >50% patients eventually require amputation.
O O O O O O O
Dry gangrene— - ANSWER necrotic "mummified" tissue without signs of infection—
O O O O O O O O O O
not a surgical emergency
O O O
Wet gangrene— - ANSWER necrotic tissue indicative of active infectious process—
O O O O O O O O O O
requires aggressive debridement or amputation to avoid sepsis
O O O O O O O
How are ankle brachial index/digital brachial index (ABIs/DBIs) and segmental pressures measur
O O O O O O O O O O O
ed? Pulse volume recordings (PVRs)? What is their significance? -
O O O O O O O O O
ANSWER Normal ABI at rest: 1.0 to 1.2, mild arterial insufficiency: 0.7 to 0.9, claudication: 0.5 to
O O O O O O O O O O O O O O O O O
0.7, rest pain and ultimately tissue necrosis: <0.4 (falsely elevated ABIs may be seen in diabetic
O O O O O O O O O O O O O O O O O
patients or those with chronic renal disease due to extensive vascular calcification).
O O O O O O O O O O O
,PVRs analyze the waveforms at sequential sites along patient's leg—
O O O O O O O O O
triphasic or biphasic waveforms, indicates more perfusion than monophasic.
O O O O O O O O
What is the half-life of heparin? Intraoperative therapeutic dosing? How is it reversed? -
O O O O O O O O O O O O O
OANSWER Half- O
life is 60 to 90 minutes. Intraoperative dosing is 70 to 100 units/kg (activating clotting time of 25
O O O O O O O O O O O O O O O O O
0 to 350 seconds if measured). Protamine sulfate: 1 mg/100 units of heparin.
O O O O O O O O O O O O
What are the 5- O O O
year patencies of common and external iliac percutaneous transluminal angioplasty (PTA) witho
O O O O O O O O O O O
ut stenting? - ANSWER Common iliac: 70% to 80%
O O O O O O O O
External iliac: 50% to 60% O O O O
What are the classic signs/symptoms of acute arterial occlusion? In what order do they present?
O O O O O O O O O O O O O O
- ANSWER The "6 P's" include: Paresthesias, Pain, Pallor, Poikilothermia, Pulselessness, Paralysis
O O O O O O O O O O O O
What percentage of emboli originate in the heart? First and second most common causes? -
O O O O O O O O O O O O O O
ANSWER 80% of peripheral emboli are due to cardiac etiology (First—
O O O O O O O O O O O
atrial fibrillation, Second—acute MI)
O O O
At what anatomic sites do atherosclerotic lesions most commonly occlude? -
O O O O O O O O O O
ANSWER Atherosclerosis forms at branch points such as carotid bifurcation, bends, and tethere
O O O O O O O O O O O O O
d segments such as superficial femoral artery as it passes through Hunter canal Emboli lodge at
O O O O O O O O O O O O O O O O
arterial bifurcation—that is, femoral bifurcation, brachial bifurcation
O O O O O O
How can a peripheral venous embolus cause occlusion in the peripheral arterial circulation? -
O O O O O O O O O O O O O
OANSWER A "paradoxical embolus" occurs when a peripheral venous thromboembolus crosses in
O O O O O O O O O O O
to the peripheral arterial circulation through a patent foramen ovale in the heart.
O O O O O O O O O O O O
What is the risk of limb loss associated with acute thromboembolic disease? What is the associa
O O O O O O O O O O O O O O O
ted mortality? - ANSWER Risk of limb loss: 8% to 22%
O O O O O O O O O O
, Thromboembolic perioperative mortality: 10% to 17% O O O O O
Name some of the indications to operate for peripheral arterial occlusive disease: -
O O O O O O O O O O O O
OANSWER Tissue necrosis, rest pain, infection, debilitating claudication refractory to nonoperativ
O O O O O O O O O O
e management (Pentoxifylline, Aspirin, Cessation of smoking, Exercise—
O O O O O O O
PACE pneumonic) NOTE—
O O
claudication is not an indication for surgery; it is best treated with supervised exercise training.
O O O O O O O O O O O O O O
What is 5-year patency rate of Fem-Pop vein grafts versus prosthetic grafts - ANSWER 5-
O O O O O O O O O O O O O O
year patency of an above-the-
O O O O
knee vein graft is 75% (no difference between in situ or reverse); prosthetic is 40% to 50%.
O O O O O O O O O O O O O O O O
5-year patency of a below-the-knee vein graft is 65%, prosthetic is 30%.
O O O O O O O O O O O
What do early (<30 day), intermediate, and late (>2 year) bypass graft failures generally represe
O O O O O O O O O O O O O O
nt? - ANSWER Early—Use of small, poor-
O O O O O O
quality vein; anastomosis to inadequate outflow artery or technical error (kink/twist of graft; inc
O O O O O O O O O O O O O
omplete lysis of valves) at the time of surgery Intermediate—
O O O O O O O O O
Intimal hyperplasia at anastomotic sites or valve sites within the graft Late—
O O O O O O O O O O O
Progression of atherosclerotic disease within the inflow or outflow vessels
O O O O O O O O O
Name the 4 calf compartments in order of compartment syndrome probability: -
O O O O O O O O O O O
ANSWER Anterior, lateral, deep posterior, superficial posterior compartment
O O O O O O O O
What is the first sign of compartment syndrome? How long after revascularization is greatest ris
O O O O O O O O O O O O O O
k? - O
ANSWER Numbness of great toe webbing is an early sign of compartment syndrome due to dee
O O O O O O O O O O O O O O O O
p peroneal nerve compression (anterior). Greatest risk occurs 4 to 6 hours after revascularizatio
O O O O O O O O O O O O O
n along with release of intracellular ions/proteins/enzymes from damaged sarcolemma.
O O O O O O O O O
What is the most common iatrogenic injury during anterior compartment fasciotomy? -
O O O O O O O O O O O
ANSWER Injury to the lateral peroneal nerve in the superior aspect of the incision
O O O O O O O O O O O O O O
