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506 Section II / General Surgery

 

Which vein runs behind the

LEFT common iliac vein

RIGHT common iliac artery?

 

Which renal vein is longer?

Left

MESENTERIC ISCHEMIA

 

 

CHRONIC MESENTERIC ISCHEMIA

 

 

What is it?

Chronic intestinal ischemia from

 

long-term occlusion of the intestinal

 

arteries; most commonly results from

 

atherosclerosis; usually in two or more

 

arteries because of the extensive

 

collaterals

What are the symptoms?

Weight loss, postprandial abdominal

 

pain, anxiety/fear of food because of

 

postprandial pain, heme occult,

 

diarrhea/vomiting

What is “intestinal angina”?

Postprandial pain from gut ischemia

What are the signs?

Abdominal bruit is commonly heard

How is the diagnosis made?

A-gram, duplex, MRA

What supplies blood to the

1. Celiac axis vessels

gut?

2. SMA

 

3. IMA

What is the classic finding

Two of the three mesenteric arteries are

on A-gram?

occluded, and there is atherosclerotic

 

narrowing of the third patent artery

What are the treatment

Bypass, endarterectomy, angioplasty,

options?

stenting

ACUTE MESENTERIC ISCHEMIA

 

 

 

What is it?

Acute onset of intestinal ischemia

What are the causes? 1. Emboli to a mesenteric vessel from the heart

2.Acute thrombosis of long-standing atherosclerosis of mesenteric artery

 

Chapter 66 / Vascular Surgery 507

What are the causes of

AFib, MI, cardiomyopathy, valve disease/

emboli from the heart?

endocarditis, mechanical heart valve

What drug has been

Digitalis

associated with acute

 

intestinal ischemia?

 

To which intestinal artery do

Superior Mesenteric Artery (SMA)

emboli preferentially go?

 

What are the signs/

Severe pain—classically “pain out of

symptoms of acute

proportion to physical exam,” no

mesenteric ischemia?

peritoneal signs until necrosis, vomiting/

 

diarrhea/hyperdefecation, heme stools

What is the classic triad of

1. Acute onset of pain

acute mesenteric ischemia?

2. Vomiting, diarrhea, or both

 

3. History of AFib or heart disease

What is the gold standard

Mesenteric A-gram

diagnostic test?

 

What is the treatment of a

Perform Fogarty catheter embolectomy,

mesenteric embolus?

resect obviously necrotic intestine, and

 

leave marginal looking bowel until a

 

“second look” laparotomy is performed

 

24 to 72 hours postoperatively

What is the treatment of acute thrombosis?

Papaverine vasodilator via A-gram catheter until patient is in the OR; then, most surgeons would perform a supraceliac aorta graft to the involved intestinal artery or endarterectomy; intestinal resection/second look as needed

MEDIAN ARCUATE LIGAMENT SYNDROME

What is it?

What is the median arcuate ligament comprised of?

Mesenteric ischemia resulting from narrowing of the celiac axis vessels by extrinsic compression by the median arcuate ligament

Diaphragm hiatus fibers

508 Section II / General Surgery

 

 

What are the symptoms?

Postprandial pain, weight loss

What are the signs?

Abdominal bruit in almost all patients

How is the diagnosis made?

A-gram

What is the treatment?

Release arcuate ligament surgically

CAROTID VASCULAR DISEASE

 

 

 

 

ANATOMY

 

 

 

 

 

Identify the following

1.

Internal carotid artery

structures:

2.

External carotid artery

 

3.

Carotid “bulb”

 

4.

Superior thyroid artery

 

5.

Common carotid artery

 

(Shaded area: common site of plaque

 

 

formation)

What are the signs/

Amaurosis fugax, TIA, RIND, CVA

symptoms?

 

Define the following terms:

 

Amaurosis fugax

Temporary monocular blindness (“curtain

 

coming down”): seen with microemboli

 

to retina; example of TIA

TIA

Transient Ischemic Attack: focal

 

neurologic deficit with resolution of all

 

symptoms within 24 hours

 

Chapter 66 / Vascular Surgery 509

RIND

Reversible Ischemic Neurologic Deficit:

 

transient neurologic impairment (without

 

any lasting sequelae) lasting 24 to 72 hours

CVA

CerebroVascular Accident (stroke):

 

neurologic deficit with permanent brain

 

damage

What is the risk of a CVA in

10% a year

patients with TIA?

 

What is the noninvasive

Carotid ultrasound/Doppler: gives

method of evaluating carotid

general location and degree of stenosis

disease?

 

What is the gold standard

A-gram

invasive method of

 

evaluating carotid disease?

 

What is the surgical treatment of carotid stenosis?

What are the indications for CEA in the ASYMPTOMATIC patient?

What are the indications for CEA in the SYMPTOMATIC (CVA, TIA, RIND) patient?

Carotid EndArterectomy (CEA): the removal of the diseased intima and media of the carotid artery, often performed with a shunt in place

Carotid artery stenosis 60% (greatest benefit is probably in patients with 80% stenosis)

Carotid stenosis 50%

Before performing a CEA in Head CT the symptomatic patient, what

study other than the A-gram should be performed?

In bilateral high-grade carotid stenosis, on which side should the CEA be performed in the asymptomatic, right-handed patient?

Left CEA first, to protect the dominant hemisphere and speech center

What is the dreaded

Stroke (CVA)

complication after a CEA?

 
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