ABSITE REVIEW: Vascular Cranial Nerves and Leg Ulcers

ABSITE REVIEW
Vascular
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
Carotid-body tumor
Blood supply from ECA

splaying of carotid bifurcation (lyre sign)
P
1
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
A. elastic compression stockings (Jobst)
B. paste gauze (Unna) boot
C. polyurethane foam dressings
D. hydrocolloid dressings (DuoDerm)
E. intermittent pneumatic compression
Q
3
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
A. elastic compression stockings (Jobst)
B. paste gauze (Unna) boot
C. polyurethane foam dressings
D. hydrocolloid dressings (DuoDerm)
E. intermittent pneumatic compression
Q
3
Q
venous stasis ulcers
3
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
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
Q3
8
Please view the

image, then select
the best answer.
(AVF) that usually
venous outflow
Both
Neither
Q3
8
Please view the

image, then select
the best answer.
(AVF) that usually
venous outflow
Both
Neither
Q3
9
Please view the

image, then select
the best answer.
(AVF) that usually
venous outflow
Both
Neither
Q3
9
Please view the

image, then select
the best answer.
(AVF) that usually
venous outflow
Both
Neither
Q4
0
Please view the

image, then select
the best answer.
An arteriovenous
fistula (AVF) that
usually requires
transposition
(superficialization) of
the venous outflow
Both
Neither
Q4
0
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
Q3
840
Q
1
Q
1
Q
1
Q
1
A 53-year-old man has a 1-week history of a painful blue Q

right first toe. Before his toe turned blue, he was able to
4
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.
A. The most appropriate treatment would be
B. systemic anticoagulation
C. ligation of the aneurysm with bypass graft
D. endovascular stent
E. operative resection of the aneurysm with primary repair
F. aneurysmorrhaphy with interposition graft
A 53-year-old man has a 1-week history of a painful blue Q

right first toe. Before his toe turned blue, he was able to
4
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.
A. The most appropriate treatment would be
B. systemic anticoagulation
C. ligation of the aneurysm with bypass graft
D. endovascular stent
E. operative resection of the aneurysm with primary repair
F. aneurysmorrhaphy with interposition graft
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 > 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 reestablished 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
Q
4
Q
A 28-year-old female body builder has the acute 5
onset of a swollen right arm. Which of the following
statements about her condition is TRUE?
A.Higher incidence in females
B.Often accompanied by neurologic symptoms
C.Not successfully treated with anticoagulation therapy
D.Definitively treated with catheter-directed
thrombolysis
E. Associated with venous gangrene of the upper
extremities
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?
A.Higher incidence in females
B.Often accompanied by neurologic symptoms
C.Not successfully treated with anticoagulation
therapy
D.Definitively treated with catheter-directed
thrombolysis
E.Associated with venous gangrene of the upper
extremities
Q
5
Q
primary axillary-subclavian vein thrombosis
5
young patients, 2:1 male:female 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
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
Q
5
Thoracic Outlet Exam
Q
5
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
Q1
Question: Which nerve/artery is commonly injured with
fracture of
the mid-shaft humerus?
Radial nerve
supracondylar fracture of the humerus?
Brachial artery

distal
radius fracture?
Median nerve
Q
A 44-year-old man with diabetes mellitus complicated by
6
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?
A. Fever is a reliable indicator of the severity of infection
B. Antimicrobial therapy alone will resolve 50% of cases
C. Swab cultures of purulent drainage are adequate
D. Magnetic resonance imaging (MRI) will not reliably
diagnose osteomyelitis in this patient
E. Immediate transmetatarsal amputation is required
Q
A 44-year-old man with diabetes mellitus complicated by
6
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?
A. Fever is a reliable indicator of the severity of infection
B. Antimicrobial therapy alone will resolve 50% of cases
C. Swab cultures of purulent drainage are adequate
D.Magnetic resonance imaging (MRI) will not reliably
diagnose osteomyelitis in this patient
E. Immediate transmetatarsal amputation is required
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
>80%.
Management
avoidance of weightbearing
immediate drainage and debridement procedures
hyperglycemic control
management of ischemia
Q
6
Q
8
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
A. revision of transmetatarsal amputation
B. immediate surgical debridement of soft tissue only
C. immediate surgical debridement, and vascular
reconstruction of pedal blood flow
D. immediate surgical debridement, with negative pressure
dressing to improve blood flow
E. immediate below-knee amputation
Q
8
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
A. revision of transmetatarsal amputation
B. immediate surgical debridement of soft tissue only
C. immediate surgical debridement, and vascular
reconstruction of pedal blood flow
D. immediate surgical debridement, with negative pressure
dressing to improve blood flow
E. immediate below-knee amputation
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
Q
8
P
2
DeBakey
Classification Aortic
Dissection
Q
9
Which of the following statements about antithrombotic
treatments is TRUE?
A.In the absence of antithrombin III, unfractionated heparin

has no significant anticoagulant effect
B.Low molecular weight heparins share the ability to
accelerate the activity of factor Xa
C.Warfarin inhibits the absorption of vitamin K from the
intestinal tract
D.Hirudin, a synthetic thrombin inhibitor, is dependent on
antithrombin III for anticoagulant activity
E. The addition of aspirin to heparin increases the
anticoagulant effect without increasing the risk of
hemorrhagic side effects
Q
Which of the following statements about antithrombotic9
treatments is TRUE?
A.In the absence of antithrombin III, unfractionated

heparin has no significant anticoagulant effect
B. Low molecular weight heparins share the ability to
accelerate the activity of factor Xa
C. Warfarin inhibits the absorption of vitamin K from the
intestinal tract
D.Hirudin, a synthetic thrombin inhibitor, is dependent on
antithrombin III for anticoagulant activity
E. The addition of aspirin to heparin increases the
anticoagulant effect without increasing the risk of
hemorrhagic side effects
Unfractionated heparin - indirect thrombin inhibitor Q

acceleration of the interaction of antithrombin III with 9
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
Q1
Which of the following statements about management of0
abdominal aortic aneurysm (AAA) is TRUE?
A. Elective operation should be considered for patients with

symptomatic AAA in the absence of significant comorbidities
B. The risk of rupture is higher in women than men for small
aneurysms
C. In an otherwise healthy 75-year-old man, a 4.5-cm
aneurysm should be repaired
D. An unreliable patient who is unlikely to comply with lifelong
surveillance should be preferentially offered endograft
versus open repair
E. Mortality is not related to the hospital's volume of AAA
repairs performed
Q1
Which of the following statements about management of0
abdominal aortic aneurysm (AAA) is TRUE?
A. Elective operation should be considered for patients with

symptomatic AAA in the absence of significant comorbidities
B.The risk of rupture is higher in women than men for
small aneurysms
C. In an otherwise healthy 75-year-old man, a 4.5-cm
aneurysm should be repaired
D. An unreliable patient who is unlikely to comply with lifelong
surveillance should be preferentially offered endograft
versus open repair
E. Mortality is not related to the hospital's volume of AAA
repairs performed
The mortality of untreated rupture of abdominal aortic Q1

0
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
Q2
supracondylar
fracture of femur?
Popliteal artery
posterior
dislocation of hip?
Sciatic nerve

posterior
dislocation of knee?
Popliteal artery
Q1
2
Which of the following statements about the natural
history of intermittent claudication is TRUE?
A.Five-year survival is > 90%

B.Most patients eventually require revascularization
to avoid amputation
C.One in 4 patients will eventually undergo major
amputation
D.Intermittent claudication is a risk factor for adverse
cardiovascular events
E. Abstinence from tobacco does not improve the
symptoms of intermittent claudication
Q1
2
Which of the following statements about the natural
history of intermittent claudication is TRUE?
A.Five-year survival is > 90%

B.Most patients eventually require revascularization
to avoid amputation
C.One in 4 patients will eventually undergo major
amputation
D.Intermittent claudication is a risk factor for
adverse cardiovascular events
E. Abstinence from tobacco does not improve the
symptoms of intermittent claudication
claudication derived from the root word "to limp

reproducible leg pain relieved with rest
ankle:brachial index (ABI) -ratio of ankle pressure to
arm pressure
normal 0.9 to 1.2
Peripheral arterial disease, ABI < 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

modifying the risk factors of systemic atherosclerosis:
smoking, obesity, hypertension, diabetes, and
hyperlipidemia
The 5-year mortality 30% to 50%, due to

Smoking cessation improves the symptoms
Q1
2
Ankle : Brachial index (ABI)

ratio of ankle pressure to arm pressure
Ankle : Arm Index (AAI)
Q1
2
normal 0.9 to 1.2

Peripheral arterial disease, ABI < 0.9
Claudication 0.40.9
Rest pain 0.20.5
Tissue loss < 0.4
Gangrene < 0.3
> 0.50 in 85% of patients with single level of
disease
< 0.50 in 95% with two or more levels of
disease
Q1
A 30-year-old man presents with a brief history of crampy,3
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
A. venous thrombectomy
B. anticoagulation with heparin
C. tissue plasminogen activator (tPA) via the superior
mesenteric artery
D. warfarin (Coumadin) anticoagulation
E. systemic tPA
Q1
A 30-year-old man presents with a brief history of crampy,3
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
A. venous thrombectomy
B.anticoagulation with heparin
C. tissue plasminogen activator (tPA) via the superior
mesenteric artery
D. warfarin (Coumadin) anticoagulation
E. systemic tPA
Q1
diagnosis of mesenteric venous thrombosis
3
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 <10% of clinically
significant mesenteric ischemia
A hypercoagulable state > 90% of patients
Q1
A 75-year-old man with a ruptured abdominal 4
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?
A.Distance from patient's home to hospital
B.Number of co-morbidities
C.Surgeon experience
D.Annual hospital volume of aneurysm repair
E. Site of aortic rupture
Q1
A 75-year-old man with a ruptured abdominal 4
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?
A.Distance from patient's home to hospital
B.Number of co-morbidities
C.Surgeon experience
D.Annual hospital volume of aneurysm repair
E. Site of aortic rupture
Q1
Ruptured abdominal aortic aneurysms (AAA)
4
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 > 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
Q1
5
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
A. buttock claudication
B. buttock necrosis
C. spinal cord ischemia
D. ischemic colitis
E. impotence
Q1
5
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
A.buttock claudication
B. buttock necrosis
C. spinal cord ischemia
D. ischemic colitis
E. impotence
Q1
Endovascular aortic aneurysm repair (EVAR) has become a
standard treatment option for aortoiliac aneurysms
5
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??
Endovascular Repair of an Abdominal Aortic Aneurysm, with the Use of an Endograft
Greenhalgh R and Powell J. N Engl J Med 2008;358:494-501
The 5 Types of Leakage of Blood into the Aneurysm, or Endoleak
The Four Types of Leakage of Blood into the Aneurysm, or Endoleak
Greenhalgh R and Powell J. N Engl J Med 2008;358:494-501
Q1
6
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
A. chronic oral anticoagulation

B. fistula ligation
C. fistula banding near the arterial anastomosis
D.balloon angioplasty of the subclavian vein stenosis
E. subclavian-jugular venous bypass
Q1
6
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
A. chronic oral anticoagulation
B. fistula ligation
C. fistula banding near the arterial anastomosis
D.balloon angioplasty of the subclavian vein stenosis
E.subclavian-jugular venous bypass
Q1
Pain and swelling in extremity after placement of an
arteriovenous access is indicative of venous hypertension
6
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 <1/3 patients
Open surgical techniques such as subclavian-jugular bypass or

jugular turndown (jugular subclavian vein transposition) better
option, especially in younger patients with reasonable longterm prognosis
Although more invasive, long-term patency and symptomatic
relief are better than with angioplasty
Q1
A 78-year-old woman with chronic atrial fibrillation is 7
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
A. mesenteric arteriogram
B. biliary excretion, eg, HIDA, scan
C. systemic urokinase
D. anticoagulation and
serial examination
A. exploratory laparotomy
Q1
A 78-year-old woman with chronic atrial fibrillation is 7
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.
A. mesenteric arteriogram
B. biliary excretion, eg, HIDA, scan
C. systemic urokinase
D. anticoagulation and
serial examination
A.exploratory laparotomy
Q1
Acute mesenteric ischemia sudden onset of
7
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
Q1
8
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.
A. administration of intravenous heparin

B. carotid duplex ultrasonography
C. cerebral imaging study
D.carotid arteriogram
E. immediate transport to the operating room for carotid
re-exploration
Q1
8
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.
A. administration of intravenous heparin

B. carotid duplex ultrasonography
C.cerebral imaging study
D.carotid arteriogram
E. immediate transport to the operating room for carotid
re-exploration
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
Q1
8
Q1
Compared with open repair, endovascular 9
repair of a 6.5-cm infrarenal abdominal aortic

aneurysm is associated with
A.reduced 30-day morbidity and mortality

B.longer recovery times due to persistent
endoleaks
C.lower incidence of colon ischemia
D.fewer re-interventions
E.lower treatment costs
Q1
Compared with open repair, endovascular 9
repair of a 6.5-cm infrarenal abdominal aortic

aneurysm is associated with
A.reduced 30-day morbidity and mortality

B.longer recovery times due to persistent
endoleaks
C.lower incidence of colon ischemia
D.fewer re-interventions
E.lower treatment costs
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 reinterventions 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
Q1
9
EVAR
OVER
DREAM
Q1
9
DREAM
DREAM (6yr f/u)
Q1
9
Q2
A 42-year-old woman presents with a recurrent stasis 0
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
Q2
A 42-year-old woman presents with a recurrent stasis 0
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
Q2
venous stasis ulcers 1% of the adult population,
0
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
Q2
A 53-year-old man presents with a 2-day history of 1
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
A. unfractionated heparin only
B. low molecular weight heparin
C. direct thrombin inhibitor
D.catheter-directed thrombolysis
E. systemic thrombolysis
Q2
A 53-year-old man presents with a 2-day history of 1
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
A. unfractionated heparin only
B. low molecular weight heparin
C. direct thrombin inhibitor
D.catheter-directed thrombolysis
E. systemic thrombolysis
Conventional therapy DVT systemic heparin followed by oral Q2

anticoagulation for 3 to 6 months
1
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
Q2
2
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
A. immediate administration of heparin, followed by longterm anticoagulation
B. systemic administration of a lytic agent
C. catheter-based lytic therapy
D. placement of a self-expanding stent
E. surgical resection of the obstructing lesion
Q2
2
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
A. immediate administration of heparin, followed by longterm anticoagulation
B. systemic administration of a lytic agent
C. catheter-based lytic therapy
D.placement of a self-expanding stent
E. surgical resection of the obstructing lesion
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 > 90%
catheter-directed lysis to treat venous
thrombosis before stent placement
Q2
2
Q2
3
Endovascular repair of an abdominal aortic

aneurysm has improved outcome over
open repair in all of the following EXCEPT
A.graft complications
B.mortality
C.cardiac complications
D.pulmonary complications
E.length of hospital stay
Q2
3
Endovascular repair of an abdominal aortic

aneurysm has improved outcome over
open repair in all of the following EXCEPT
A.graft complications
B.mortality
C.cardiac complications
D.pulmonary complications
E.length of hospital stay
Q2
Which of the following statements about arteriovenous4
fistulas (AVFs) for hemodialysis access in patients with
end-stage renal disease is TRUE?
A. AVFs should be placed immediately after patients have

started dialysis
B. Over 50% of such patients are being dialyzed through
AVFs
C. The radiocephalic fistula can be done in over 50% of all
patients
D.If an AVF fails to mature properly, secondary operations
are rarely successful
E. For a patient with small vessels, a prosthetic graft will
provide a higher patency rate than a radiocephalic fistula
Q2
Which of the following statements about arteriovenous 4
fistulas (AVFs) for hemodialysis access in patients with endstage renal disease is TRUE?
A.AVFs should be placed immediately after patients have

started dialysis
B.Over 50% of such patients are being dialyzed through AVFs
C.The radiocephalic fistula can be done in over 50% of all
patients
D.If an AVF fails to mature properly, secondary operations are
rarely successful
E.For a patient with small vessels, a prosthetic graft
will provide a higher patency rate than a
radiocephalic fistula
Q2
In any given year, some 240,000 patients with end-stage
renal disease are being treated with maintenance
4
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
Q2
5
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
A. analgesics and antibiotics with discharge home
B. hospital admission, serial examinations
C. hospital admission, hyperbaric oxygen
D. carpal tunnel release
E. volar and dorsal forearm fasciotomy
Q2
5
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
A. analgesics and antibiotics with discharge home
B.hospital admission, serial examinations
C. hospital admission, hyperbaric oxygen
D. carpal tunnel release
E. volar and dorsal forearm fasciotomy
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 > 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
Q2
5
Q2
5
A 57-year-old man has the

angiogram shown. Which of the
following statements is TRUE?
A.Anticoagulation is indicated
B.Limb loss is likely without
revascularization
C.He is likely to complain of pain
in his foot with walking
D.He has a decreased life
expectancy
E. Antiplatelet therapy has no role
in the medical management of
this patient
Q2
7
A 57-year-old man has the

angiogram shown. Which of the
A.Anticoagulation is indicated
B.Limb loss is likely without
revascularization
C.He is likely to complain of pain
in his foot with walking
D.He has a decreased life
expectancy
E. Antiplatelet therapy has no role
in the medical management of
this patient
Q2
7
Q2
occlusion of the superficial femoral artery
7
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
Which of the following statements about the

findings shown in this computed tomographic (CT)
scan is TRUE?
A.This is the most common site of aneurysmal
disease
B.Successful surgical repair eliminates any further
enlargement
C.Rupture is more likely to occur than thrombosis
D.Embolization from the aneurysm is a continuous
risk
E.There is no role for thrombolytic therapy
Q2
8
Q2
8
Which of the following statements about the
findings shown in this computed tomographic (CT)
scan is TRUE?
A.This is the most common site of aneurysmal

disease
B.Successful surgical repair eliminates any further
enlargement
C.Rupture is more likely to occur than thrombosis
D.Embolization from the aneurysm is a
continuous risk
E.There is no role for thrombolytic therapy
Q2
aneurysms of both popliteal arteries (the left is larger than the right)
Abdominal aortic aneurysms (AAA) occur more frequently, but
8
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
Which of the following statements

about the lesion shown is TRUE?
A. If the patient is otherwise healthy
and asymptomatic, this lesion
should be managed medically
B. The patient is at increased risk of
stroke, heart attack, and death with
or without operative intervention
C. Endovascular treatment is
associated with improved outcome
when compared with operation
D. Successful operative or
endovascular intervention
eliminates the need for continued
medical therapy
E. If the patient has already had a
stroke, operative intervention is not
indicated
Q2
9

about the lesion shown is TRUE?
A. If the patient is otherwise healthy
and asymptomatic, this lesion
should be managed medically
B.The patient is at increased risk
of stroke, heart attack, and
death with or without
operative intervention
C. Endovascular treatment is
associated with improved outcome
when compared with operation
D. Successful operative or
eliminates the need for continued
medical therapy
E. If the patient has already had a
stroke, operative intervention is
not indicated
Q2
9
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
Q2
9
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?
A. Treatment will require ostomy formation
B. A negative upper endoscopy eliminates
the need for operation
C. Graft excision and extra-anatomic
reconstruction should be performed
immediately
D. Systemic antibiotics should be started
immediately
E. Percutaneous drainage is adequate
therapy
Q3
1
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.
his diagnosis and management is TRUE?
A. Treatment will require ostomy formation
B. A negative upper endoscopy eliminates
the need for operation
C. Graft excision and extra-anatomic
reconstruction should be performed
immediately
D. Systemic antibiotics should be started
immediately
E. Percutaneous drainage is adequate
therapy
Q3
1
Q3
1
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 perioperative period
Aortoenteric fistulas most frequently occur at the site of the proximal anastomosis
of the graft to the aorta and involve the third portion of the duodenum
Upper endoscopy may confirm this diagnosis, but might dislodge an already
tenuous clot within the lumen of the bowel - best performed in the operating room
Small bowel fistulas in this setting may be closed primarily and excluded from the
site of aortic repair with a wrap of omentum or well-vascularized soft tissue
complete graft excision with aggressive retroperitoneal debridement and extraanatomic reconstruction has been recommended
Mortality rates remain at 30% in the immediate postoperative period
For normotensive patients who are not actively bleeding, a radionuclide-labeled
WBC scan may provide additional useful information, such as whether the graft in
the region of the groins is also infected
staged procedures - Extra-anatomic bypass may be performed first after
appropriate antibiotics have been administered and the patient's condition has
stabilized, followed by laparotomy and excision of all infected graft material
-improved patient survival
survivors remain at risk for aortic stump blowout, thrombosis of the extraanatomoic bypass, and amputation of the extremities
Most of these infections develop 5 or more years after initial operation and are
from fastidious organisms such as Staphylococcus epidermidis
low virulence of these organisms has led many to suggest that long-term
antibiotics in conjunction with aggressive debridement with in situ reconstruction
may be possible
antibiotic-impregnated grafts, arterial homografts, and autogenous vein grafts
harvested from the patient's own deep femoral system of veins
A 65-year-old woman with a long

history of varicose veins has had the
ulcer shown, above her medial
malleolus, for several months.
about her condition is TRUE?
A. Preoperative evaluation to identify
sources of venous reflux, tributaries,
and vein size will not change
management
B. Based on its location, this ulcer is
arterial in etiology
C. This is likely the result of a
duplication of the greater saphenous
vein
D. Therapy should be directed at
eliminating venous hypertension
E. Greater saphenous vein stripping will
be required to achieve wound healing
Q3
2
A 65-year-old woman with a long

history of varicose veins has had the
ulcer shown, above her medial
malleolus, for several months.
about her condition is TRUE?
A. Preoperative evaluation to identify
sources of venous reflux, tributaries,
and vein size will not change
management
B. Based on its location, this ulcer is
arterial in etiology
C. This is likely the result of a
duplication of the greater saphenous
vein
D.Therapy should be directed at
eliminating venous hypertension
E. Greater saphenous vein stripping will
be required to achieve wound healing
Q3
2
Q3
Conservative measures to reduce venous
2
hypertension
compression dressings, such as an Unna
boot or Profore dressing
rule out deep venous thrombosis
saphenofemoral junction can be
evaluated for the presence of reflux
Elimination of the proximal segment and
its tributaries may be all that is required
to alleviate venous hypertension and
promote wound healing
Reflux along the entire length of the
greater saphenous vein remains an
indication for complete excision or
ablation
P
3
Compartments of the Lower Leg
Compartment
Muscles
Tibialis anterior,
Extensor hallucis
Anterior compartment longus, Extensor
digitorum longus,
Peroneus tertius
Neurovascular
structures
deep peroneal nerve
Anterior Tibial vessels
(AT)
Lateral compartment
Peroneus longus,
Peroneus brevis
superficial peroneal
nerve
Deep posterior
compartment
tibial nerve
Tibialis posterior,
posterior tibial
Flexor hallucis longus,
vessels (PT)
Flexor digitorum
peroneal artery
longus, Popliteus
Q3
3

about common iliac artery aneurysms
is TRUE?
A.Surgical repair is not recommended until it
is 5 cm
B.Endovascular repair is not recommended
C.They are usually infectious in etiology
D.They frequently rupture when < 3 cm
E.They are most often associated with other
aneurysms
Q3
3

about common iliac artery aneurysms
is TRUE?
A.Surgical repair is not recommended until it
is 5 cm
B.Endovascular repair is not recommended
C.They are usually infectious in etiology
D.They frequently rupture when < 3 cm
E.They are most often associated with
other aneurysms
Q3
Isolated common iliac artery aneurysms occur in only
0.1% to 1.9% of all patients with aneurysmal disease
3
atypical causes such as infection, trauma, medial necrosis,
fibrodysplasia, cystic necrosis, Marfan's, or nonspecific
inflammatory conditions
liac artery aneurysms are found in 10% to 20% of patients
with AAA
difficulty in palpating these aneurysms and their
asymptomatic nature, rupture and mortality rates are high
one retrospectively reviewed series, no significant rate of
expansion was seen over 4 years in aneurysms < 3 cm,
and no deaths were attributable to aneurysmal disease.
Currently, repair is not recommended for aneurysms < 3
cm
Endovascular treatment options both in conjunction with
AAA repair individually
covered stent and endovascular coiling of an internal iliac
artery if a sufficient seal zone of 1.5 cm cannot be
obtained proximal to its origin to decrease flow to the
aneurysm sac
Preservation of the contralateral internal iliac flow and
collaterals is important to preserve flow to the pelvis
Development of the lower extremity

postthrombotic syndrome (stasis,
edema, pigmentation, ulceration)
A.is most likely in patients with multisegment thrombosis
B.is effectively prevented by a 6-month
course of low molecular-weight heparin
C.occurs in15% to 20% of all patients with
deep vein thrombophlebitis
D.is uncommon after isolated calf vein
thrombophlebitis
E.is due entirely to valvular insufficiency
Q3
4
Development of the lower extremity

postthrombotic syndrome (stasis,
edema, pigmentation, ulceration)
A.is most likely in patients with multisegment thrombosis
B.is effectively prevented by a 6-month
course of low molecular-weight heparin
C.occurs in15% to 20% of all patients with
deep vein thrombophlebitis
D.is uncommon after isolated calf vein
thrombophlebitis
E.is due entirely to valvular insufficiency
Q3
4
The postthrombotic syndrome is a highly morbidQ3

late complication of deep vein thrombophlebitis 4
(DVT) of the lower extremities
Within 5 years of the sentinel episode, 40% to
60% of patients will develop clinically significant
signs and symptoms of the syndromechronic leg
edema and pain, dermatitis, and ulceration
The most common inciting factor is a recurrent
episode of DVT after resolution of the initial
insult
Obesity and inherited coagulopathies also place
patients at greater risk
valvular damage is permanent and venous
reflux
Permanent obstruction of one or more venous
segments, resulting in outflow obstruction and
venous hypertension
ineffective calf muscular pump function
Q3
5
A 77-year-old woman presents with a cold

left hand. After operative embolectomy,
the next step in this patient's evaluation
should be
A.magnetic resonance angiogram of the

subclavian arteries
B.duplex examination of the carotid arteries
C.echocardiogram
D.cardiac catheterization
E.Adson's maneuver
Q3
5
A 77-year-old woman presents with a cold

left hand. After operative embolectomy,
the next step in this patient's evaluation
should be
A.magnetic resonance angiogram of the

subclavian arteries
B.duplex examination of the carotid arteries
C.echocardiogram
D.cardiac catheterization
E.Adson's maneuver
Acute extremity ischemia can be caused by either Q3

5
thrombosis or embolism
Distinguishing between the two is often difficult
history of acute onset that can be pinpointed
exactly in time is more consistent with an embolic
phenomenon
Peripheral emboli most commonly arise from the
heart
valvular heart disease or atrial arrhythmia
aneurysms of the upper extremity arteries with

subsequent mural thrombus and embolism,
embolism from an aortic plaque, or embolism
associated with arterial instrumentation
Echocardiography - search for valvular
abnormalities, thrombosis in any of the cardiac
chambers, and search for septal defects
Magnetic resonance angiography (MRA) of the
subclavian arteries would be indicated if
echocardiography is negative, duplex better initial
screening test
Q3
Three days after knee arthroscopy, a 35-year-old6
man presents with mild dyspnea on exertion. His
temperature is 100F. His chest is clear to
auscultation, except for right lower lobe rales.
Minimal knee swelling is noted at the
arthroscopy site. His WBC count is 12,400/mm 3
and D-dimer level is normal. The chest x-ray
shows obscuring of the right hemidiaphragm.
The next diagnostic test should be
A.bilateral lower extremity duplex examination

B.contrast venography
C.ventilation/perfusion scan
D.computed tomographic (CT) angiography
E.sputum culture
Q3
Three days after knee arthroscopy, a 35-year-old6
man presents with mild dyspnea on exertion. His
temperature is 100F. His chest is clear to
auscultation, except for right lower lobe rales.
Minimal knee swelling is noted at the
arthroscopy site. His WBC count is 12,400/mm 3
and D-dimer level is normal. The chest x-ray
shows obscuring of the right hemidiaphragm.
The next diagnostic test should be
A.bilateral lower extremity duplex examination

B.contrast venography
C.ventilation/perfusion scan
D.computed tomographic (CT) angiography
E.sputum culture
Q3
Whenever a patient presents with respiratory symptoms
after an operation, deep venous thrombosis (DVT) and
6
subsequent pulmonary embolus must be among the
differential diagnoses
DVT in only 20% to 35%
diagnostic tests are time-consuming, costly, or have a finite
complication rate
Serum D-dimer is a rapid and simple screening test that
may be used to eliminate up to 80% of patients without
venous thromboembolism (VTE)
D-dimer is a degradation product of cross-linked fibrin
Although levels are elevated during any thromboembolic
event, many nonthrombotic events, including operation,
may cause transient elevations in D-dimer
For this reason, documentation of suspected VTE under
such circumstances requires additional diagnostic work-up
D-dimer has a negative predictive value of 96% to 100%
When combined with a low clinical suspicion in a patient
with a likely alternative diagnosis, the negative predictive
values approach 98% to 99%
For this patient with a presumptive diagnosis of pneumonia
and a normal D-dimer level, significant VTE is virtually
excluded, making any further diagnostic test unnecessary
Q3
7
Following a routine knee arthroscopy, a

healthy 33-year-old man develops an
uncomplicated femoral deep venous
thrombosis. A hypercoagulable
evaluation is negative. Anticoagulation
should be given
A.for 6 weeks
B.for 3 months
C.for 1 year
D.until symptoms resolve
E.for life
Q3
7
Following a routine knee arthroscopy, a

healthy 33-year-old man develops an
uncomplicated femoral deep venous
thrombosis. A hypercoagulable
evaluation is negative. Anticoagulation
should be given
A.for 6 weeks
B.for 3 months
C.for 1 year
D.until symptoms resolve
E.for life
The optimal duration of oral anticoagulation for an

uncomplicated deep venous thrombosis (DVT) has long been
debated
Traditional teaching 3- to 6-month
complication rate with warfarin (Coumadin)
DVT isolated to the calf without proximal extension or
pulmonary embolism, 6 weeks of treatment might be
sufficient
The American College of Chest Physicians Consensus
Statement recommends 3 months of treatment for a firsttime DVT episode with a known transient, reversible risk
factor, as in this patient
Longer periods of treatment (6 months to 1 year) are
recommended for patients with permanent risk factors
(obesity, varicosity, heart failure, immobile status,
malignancy, and known thrombophilia) or idiopathic
thrombosis (no known risk factors)
Many patients in the latter group may have an undiagnosed
hypercoagulable state with estimates ranging from as little
as 1% to as high as 30% of patients presenting with DVT
A number of thrombophilic conditions have been identified:
Anticardiolipin antibody syndrome, antithrombin III
deficiency, protein C and S levels deficiency, and factor V
Leiden are the most common
Q3
7
Q3
7
Embolism vs. Thrombosis
P
4
Q4
Nonoperative management is MOST appropriate 1
for
A.a 6-cm pseudoaneurysm of the common

femoral artery after cardiac catheterization
B.intimal flap in the popliteal artery after posterior
knee dislocation that is not flow-limiting
C.pulsatile bleeding from a stab wound to the
thigh in a hemodynamically stable patient
D.large traumatic arteriovenous fistula between
the superficial femoral artery and vein from a
low-velocity gunshot wound
E. cool, pulseless foot after external fixation of a
femur fracture
Nonoperative management is MOST

appropriate for
A.a 6-cm pseudoaneurysm of the common
femoral artery after cardiac catheterization
B.intimal flap in the popliteal artery after
posterior knee dislocation that is not
flow-limiting
C.pulsatile bleeding from a stab wound to the
thigh in a hemodynamically stable patient
D.large traumatic arteriovenous fistula between
the superficial femoral artery and vein from a
low-velocity gunshot wound
E.cool, pulseless foot after external fixation of a
femur fracture
Q4
1
Q4
Increasingly, nonoperative management has been
successfully applied to selected traumatic vascular injuries 1
In particular, minor intimal injuries that involve less than 50%
of the arterial diameter and are not flow limiting usually heal
spontaneously (image 1)
intervention is appropriate for most arterial injuries, including
occlusions resulting in ischemia, persistent hemorrhage,
arteriovenous fistula, and large pseudoaneurysms
Arterial spasm (image 2) is frequently observed in arteries
adjacent to traumatic soft tissue injuries and typically does
not require specific treatment
Q4
Most traumatic arteriovenous fistulas (image 3) should be treated
either by coil embolization or surgical ligation because of their
1
tendency to enlarge with time
Arterial occlusion (image 4) usually warrants surgical intervention
unless the patient's overall condition precludes surgical intervention or
redundant circulation to the affected part is believed to be sufficient to
eliminate ischemia
Extravasation of contrast (image 5) during angiography indicates
ongoing hemorrhage requiring definitive treatment, either in the form
of catheter-based intervention or surgical repair
While small (< 2 cm) posttraumatic, eg, after cardiac catheterization,
pseudoaneurysms can be safely observed in anticipation of
spontaneous thrombosis, larger pseudoaneurysms require treatment
ultrasound-guided compression, percutaneous thrombin injection, and
conventional surgical repair.
Q4
1
Image 6 demonstrates a
large pseudoaneurysm
arising from the profunda
femoris artery after a stab
wound to the groin. One
coil has already been
placed
A 40-year-old male unrestrained driver is brought to the emergency

department after being ejected from his car during a motor vehicle
crash.. Four hours after injury, he is in class IV hemorrhagic shock
with a Glasgow coma scale score of 14. Core temperature is 34C,
and he has a base deficit of -18. After primary and secondary
survey, his only injury is an isolated severely comminuted open
distal femur fracture
Focused assessment with sonography for trauma (FAST) is negative,
but he has active bleeding from a crush injury to the mid thigh.
The patient is taken to the operating room for ongoing arterial and
venous bleeding from his thigh wound. Despite ongoing massive
resuscitation, he remains in shock and is hypothermic (temperature
< 34C), acidotic (pH < 7.20), and coagulopathic (INR > 1.5).
The most appropriate choice in management now would be
A. above-knee amputation of the right lower extremity

B. angiography of the right lower extremity followed by external
fixation of the right tibia and femur
C. right below-knee amputation with exploration of the femoral vessels
and repair followed by external fixation of both femurs
D. immediate ligation of the superficial femoral artery followed by
external fixation of the fractures
E. application of a tourniquet to the right thigh and delayed vascular
reconstruction
Q4
2
A 40-year-old male unrestrained driver is brought to the emergency

department after being ejected from his car during a motor vehicle
crash.. Four hours after injury, he is in class IV hemorrhagic shock
with a Glasgow coma scale score of 14. Core temperature is 34C,
and he has a base deficit of -18. After primary and secondary
survey, his only injury is an isolated severely comminuted open
distal femur fracture
Focused assessment with sonography for trauma (FAST) is negative,
but he has active bleeding from a crush injury to the mid thigh.
The patient is taken to the operating room for ongoing arterial and
venous bleeding from his thigh wound. Despite ongoing massive
resuscitation, he remains in shock and is hypothermic (temperature
< 34C), acidotic (pH < 7.20), and coagulopathic (INR > 1.5).
The most appropriate choice in management now would be
A. above-knee amputation of the right lower extremity

B. angiography of the right lower extremity followed by external
fixation of the right tibia and femur
C. right below-knee amputation with exploration of the femoral vessels
and repair followed by external fixation of both femurs
D. immediate ligation of the superficial femoral artery followed by
external fixation of the fractures
E. application of a tourniquet to the right thigh and delayed vascular
reconstruction
Q4
2
likelihood of achieving a functional limb versus the Q4

2
problems associated with limb salvage (time
involved, duration of disability, medical risks,
socioeconomic costs, number of operations and
hospitalizations, etc)
The absolute indication for amputation in trauma
remains an ischemic limb with unreconstructable
vascular injury in a patient with hypothermia,
metabolic acidosis, and coagulopathy
Massively crushed muscle and ischemic tissue can
release myoglobin and cytokines, leading to a
systemic inflammatory response syndrome,
resulting in renal failure, adult respiratory distress
syndrome, and even death
Prolonged attempts at limb salvage, even though
technically possible, may endanger the patient's
life and generally should be avoided
Q4
2
Foot Amputations
Amputation of any part of the foot.
This includes mid tarsal amputations,
Lisfranc amputation, Boyds
amputation, and Symes amputation
Transtibial Amputations (below
the knee)
Amputation occurs at any level from
the knee to the ankle
Knee Disarticulation
Amputation occurs at the level of the
knee joint
Transfemoral Amputations (above
knee ):
Amputation occurs at any level from
the hip to knee joint
Hip Disarticulation:
Amputation is at the hip joint with the
entire thigh portion being removed.
P2
A 27-year-old woman sustains a blunt

carotid injury. Carotid angiography
demonstrates a carotid dissection beginning
in the bulb and extending to the petrous
portion. A small residual lumen is present.
The optimal treatment would be
A.carotid artery stent placement
B.systemic anticoagulation with
unfractionated heparin
C.carotid exploration
D.external carotid-internal carotid (ECIC)
bypass
E.low molecular weight heparin (30
mg/kg/day)
Q4
4
A 27-year-old woman sustains a blunt

carotid injury. Carotid angiography
demonstrates a carotid dissection beginning
in the bulb and extending to the petrous
portion. A small residual lumen is present.
The optimal treatment would be
A.carotid artery stent placement
B.systemic anticoagulation with
unfractionated heparin
C.carotid exploration
D.external carotid-internal carotid (ECIC)
bypass
E.low molecular weight heparin (30
mg/kg/day)
Q4
4
Q4
4
Blunt carotid artery injuries are potentially devastating injuries due to neurologic
complications
Early detection and treatment remain the goals of management
hyperextension/rotation injuries sustained in high-impact motor vehicle crashes
much smaller percentage are caused by a direct blow to the neck
Five different mechanisms for the development of traumatic carotid artery:
direct trauma to the artery
hyperextension-rotation of the head with stretching of supra-aortic vessels
blunt intra-oral trauma
basal skull or mandibular fractures
combined chest-head injuries with carotid stretching
most common mechanism is a direct blow to the head with hyperextension-rotation of the
neck, which causes stretching of the internal carotid artery over the transverse processes of
the first and second cervical vertebrae
Carotid artery dissection typically causes headache or neck ache, followed after hours to days
by focal motor or sensory deficits
carotid four-vessel angiography remains the gold standard, CTA now
Treatment options: observation, antithrombotic therapy, open surgical repair of the affected
carotid artery, and endovascular carotid artery treatment
mainstay systemic anticoagulation with intravenous unfractionated heparin, which has been
shown to prevent progression of injury to a higher injury grade, to reduce the number of
strokes, and to prevent neurologic deterioration
Deteriorating or fluctuating neurologic symptoms might be an indication for surgical or
ECIC bypass is a surgical treatment option that is not indicated in this case.
Overall mortality resulting from posttraumatic carotid artery dissection varies from 5% to 40%
with neurologic morbidity from 12% to 80%, with bilateral lesions being the most severe
Q4
5
A 53-year-old woman undergoes coronary artery bypass grafting

and mitral valve replacement with a St. Jude mechanical
prosthesis. Warfarin (Coumadin) therapy is initiated
postoperatively, but on postoperative day 5 she has the acute
onset of right calf pain, swelling, and tenderness. Duplex
scanning demonstrates acute deep venous thrombosis of the
right femoral-popiliteal veins. Intravenous unfractionated heparin
therapy is begun.
On postoperative day 9, she has the acute onset of shortness of
breath, hypoxemia, and chest pain. Computed tomographic (CT)
angiography demonstrates multiple, bilateral pulmonary emboli.
In addition, her platelet count has fallen to 50,000.
Definitive management of this problem should be
A. discontinuing unfractionated heparin
B. discontinuing unfractionated heparin and beginning low
molecular weight heparin
C. discontinuing unfractionated heparin and beginning argatroban
D. continuing unfractionated heparin and placing an inferior vena
cava filter
E. continuing unfractionated heparin and immediate platelet
transfusion
Q4
5
A 53-year-old woman undergoes coronary artery bypass grafting

and mitral valve replacement with a St. Jude mechanical prosthesis.
Warfarin (Coumadin) therapy is initiated postoperatively, but on
postoperative day 5 she has the acute onset of right calf pain,
swelling, and tenderness. Duplex scanning demonstrates acute
deep venous thrombosis of the right femoral-popiliteal veins.
Intravenous unfractionated heparin therapy is begun.
On postoperative day 9, she has the acute onset of shortness of
breath, hypoxemia, and chest pain. Computed tomographic (CT)
angiography demonstrates multiple, bilateral pulmonary emboli. In
addition, her platelet count has fallen to 50,000.
Definitive management of this problem should be
A. discontinuing unfractionated heparin

B. discontinuing unfractionated heparin and beginning low molecular
weight heparin
C. discontinuing unfractionated heparin and beginning
argatroban
D. continuing unfractionated heparin and placing an inferior vena cava
filter
E. continuing unfractionated heparin and immediate platelet
transfusion
heparin-induced thrombocytopenia (HIT)

potentially catastrophic generalized thrombotic disorder triggered by heparin therapy
begins 4 to 14 days after initiation of therapy with intravenous unfractionated heparin,
although it can be associated with any type of heparin, given at any dose and by any
route
risk of developing HIT is 2% to 5%
diagnosis should be suspected whenever the platelet count < 150,000, or decreased
50% or more from baseline
Thrombotic complications are responsible for the severe morbidity and mortality
associated with HIT
-2/3 of patients with HIT may have thromboembolic complications
HIT has two major subtypes
Type 1 is associated with a mild thrombocytopenia, usually occurs within 4 days of
starting therapy, is not immune mediated, appears to be caused by a direct
agglutinating effect of heparin on platelets, is not associated with thrombosis, and
resolves despite the continuation of heparin therapy
HIT type 2 is associated with severe thrombocytopenia and/or a significant fall in the
baseline platelet count, usually occurring 4 to 14 days after heparin therapy is initiated.
It is immune mediated and may be associated with both venous and arterial thrombosis.
Type 2 HIT is generally associated with intravenous infusion of unfractionated heparin,
but has also been reported with subcutaneous low-dose heparin, heparin flushes,
heparin-coated catheters, and low molecular weight heparins (LMWH)
immediate discontinuation of unfractionated
Start direct thrombin inhibitor such as argatroban, bivalirudin, or lepirudin - inhibit the
formation of fibrin-bound thrombin, preventing thrombus extension and growth.
Platelet transfusion is contraindicated because it can promote thrombosis in the setting
of HIT
Q4
5
Blocks glycoprotein IIb/IIIa receptor

A.Aspirin
B.Clopidogrel (Plavix)
C.Abciximab (Reopro)
D.Cilostazol (Pletal)
E.Ibuprofen
Q4
6
Blocks glycoprotein IIb/IIIa receptor

A.Aspirin
B.Clopidogrel (Plavix)
C.Abciximab (Reopro)
D.Cilostazol (Pletal)
E.Ibuprofen
Q4
6
Aspirin
relatively weak antiplatelet agent - blocks conversion of arachidonic acid to thromboxane by
permanently inactivating the cyclo-oxygenase activity of the prostaglandin synthase-1 (COX-1) and
prostaglandin synthase-2 (COX-2)
effect lasts for the lifetime of the platelet
cessation of aspirin 5 days before operation
Clopidogrel (Plavix) and ticlopidine (Ticlid)
thienopyridenes with strong platelet inhibitory properties
selectively inhibit ADP receptor-mediated platelet aggregation
ticlopidine can cause thrombocytopenic purpura and neutropenia
clopidogrel should be discontinued at least 5 to 7 days before elective operations
If an emergency operation is required sooner, then platelet transfusions may be required
Abciximab (Reopro)
inhibit the platelet glycoprotein IIb/IIIa receptor
These drugs represent the most potent and expensive antiplatelet agents
used in patients at high risk for adverse coronary events
Bleeding complications are significantly increased, and severe thrombocytopenia occurs in 1% to 2%
of patient.
The antiplatelet effects usually disappear within 12 hours
Cilostazol (Pletal)
reversible phosphodiesterase III inhibitor that allows for increased availability of cAMP, leading to
vasodilation and platelet inhibition
used to improve walking distance in patients with intermittent claudication
relatively weak inhibitor of platelet aggregation, and co-administration with aspirin or warfarin does
not lead to significant changes in coagulation parameters
bleeding is a reported side effect, so discontinue at least 5 to 7 days before elective operation
Nonsteriodal anti-inflammatory drugs (NSAIDs)
inhibit thromboxane-dependent platelet function by reversibly inhibiting COX-1
All platelet effects are reversed within 24 hours of drug cessation
Q4
6
Q1
2
Question: At what spinal level does the spinal artery
of
Adamkiewicz usually arise?
T8-L1
Q1
2

thromboangiitis obliterans (Buerger's disease) is
TRUE?
Q1
1
A.Women outnumber men 4:1

B.It is caused by a primary arterial infection with
chlamydia
C.In a smoker, tobacco withdrawal should be gradual to
avoid rebound arterial vasospasm
D.It is characterized by thrombotic occlusions of smalland medium-sized arteries
E. Despite complete abstinence from nicotine, most
patients eventually progress to major limb loss

thromboangiitis obliterans (Buerger's disease) is
TRUE?
Q1
1
A.Women outnumber men 4:1

B.It is caused by a primary arterial infection with
chlamydia
C.In a smoker, tobacco withdrawal should be gradual to
avoid rebound arterial vasospasm
D.It is characterized by thrombotic occlusions of
small- and medium-sized arteries
E.Despite complete abstinence from nicotine, most
patients eventually progress to major limb loss
Q1
Thromboangiitis obliterans (Buerger's disease)
1
chronic arterial inflammatory condition of unknown
etiology
arterial occlusion in medium and small extremity
arteries
Major risk factors for atherosclerosis must be absent,
proximal sources of emboli must be excluded, as well
as underlying autoimmune disease and
hypercoagulable states
Both men and women can be affected, but most male
Many patients develop a form of superficial
thrombophlebitis that can be helpful in establishing
the diagnosis
Complete abstinence from tobacco in all forms
(including chewing tobacco and snuff) is the only
known effective treatment
Most patients are unable to quit smoking
If nicotine exposure is not curtailed, amputation rates
can approach 80% to 90%
Cessation of tobacco use can reduce this rate by 50%
ABSITE REVIEW
Vascular
Jessica OConnell, MD
January 25, 2012
ABSITE REVIEW
Vascular & Orthopedics
Jessica OConnell, MD
February 23, 2011
A.
B.
C.
D.
E.
F.
A 68-year-old woman with hypertension, coronary artery disease, and

a long history of Crohn's disease present with a 20-lb weight loss and
deep, aching abdominal pain after eating, severe enough that she has
markedly decreased her food intake. She has never been operated on
for Crohn's disease of the terminal ileum, which has required only one
hospitalization and has been previously well-controlled with
mesalamine (Pentasa).
Physical examination shows a flat, soft, nondistended abdomen
without masses. Rectal examination is normal and stool is hemoccult
negative. Abdominal films show no evidence of obstruction. The
abdominal-pelvic computed tomographic (CT) scan shown is obtained.
The next step in her management should be
esophagogastroduodenoscopy
capsule endoscopy
visceral angiogram
ileocecal resection
colonoscopy
Q
1
A 68-year-old woman with hypertension, coronary artery disease, and

a long history of Crohn's disease present with a 20-lb weight loss and
deep, aching abdominal pain after eating, severe enough that she has
markedly decreased her food intake. She has never been operated on
for Crohn's disease of the terminal ileum, which has required only one
hospitalization and has been previously well-controlled with
mesalamine (Pentasa).
Physical examination shows a flat, soft, nondistended abdomen
without masses. Rectal examination is normal and stool is hemoccult
negative. Abdominal films show no evidence of obstruction. The
abdominal-pelvic computed tomographic (CT) scan shown is obtained.
A. The next step in her management should be

B. esophagogastroduodenoscopy
C. capsule endoscopy
D. visceral angiogram
E. ileocecal resection
F. colonoscopy
Q
1
history of Crohn's disease over a long period of time is somewhat

confusing
Think about partial obstruction from Crohn's disease in terminal ileum
abdominal films & CT no obstruction or bowel wall thickening
history is suggestive of chronic mesenteric ischemia
aching (rather than cramping) abdominal pain after eating, weight loss,
and food fear
CT - heavy calcification in aorta
dense calcification SMA take-off
visceral angiogram with lateral views of the aorta
Visceral angina is commonly seen in women
classic triad of weight loss, postprandial epigastric pain 30 to 45
minutes after eating, and avoidance of eating.
frequently lost so much weight that intra-abdominal malignancy is a
concern
commonly undergo an extensive evaluation before correct dx
duplex scanning of the aorta/visceral vessels may be adequate
conventional angiography with both anteroposterior and lateral views
Variety of therapeutic approaches
antegrade bypass grafting from aorta

retrograde bypass grafting from infrarenal aorta or one of iliac arteries
endarterectomy of the affected vessels
percutaneous approaches PTA +/- stent
Whether all or only the symptomatic mesenteric vessels need be revascularized is controversial. Most studies favor complete
revascularization of all of the diseased vessels.
Q
1
Q
2
Which of the following is the most appropriate candidate for
protected carotid-artery stenting?
A.Healthy 60-year-old man with amaurosis fugax of the left
eye and an 80% stenosis of the left internal carotid artery
(ICA)
B.Healthy 70-year-old woman with a 50% asymptomatic
stenosis of the left ICA
C.69-year-old man with severe congestive heart failure, left
ventricular ejection fraction of 20%, and a 60% asymptomatic
D.72-year-old man with chronic obstructive pulmonary disease
(FEV1 =0.40), episodes of intermittent right arm weakness,
and 90% stenosis of the left ICA
E.60-year-old diabetic man with unexplained right eye
blindness and 50% stenosis of the left ICA
Q
2
Which of the following is the most appropriate candidate for
protected carotid-artery stenting?
A.Healthy 60-year-old man with amaurosis fugax of the left
eye and an 80% stenosis of the left internal carotid artery
(ICA)
B.Healthy 70-year-old woman with a 50% asymptomatic
C.69-year-old man with severe congestive heart failure, left
ventricular ejection fraction of 20%, and a 60% asymptomatic
D.72-year-old man with chronic obstructive pulmonary disease
(FEV1 =0.40), episodes of intermittent right arm weakness,
and 90% stenosis of the left ICA
E.60-year-old diabetic man with unexplained right eye
blindness and 50% stenosis of the left ICA
High Risk - Medical:
High Risk for CEA
clinically significant cardiac disease

congestive heart failure, abnormal stress test, EF <30%, need for open-heart
surgery, MI within 4 weeks, CABG within 6 months
severe pulmonary disease

Dialysis dependent renal failure
age > 80 years
High Risk - Surgical:

contralateral carotid occlusion
contralateral laryngeal nerve palsy
previous radical neck surgery
radiation therapy to the neck
recurrent stenosis after endarterectomy
high lesion (above C2)
Tracheostomy
NASCET Results
North American Symptomatic Carotid

Endarterectomy Trial
significant benefit of CEA in patients with 70% to

99% symptomatic stenosis
Two-year ipsilateral stroke risk

26% in the medically treated patients
9% in the CEA group (P <.001; ARR 17.0%; NNT
= 6)
Beneficial effect of carotid endarterectomy in symptomatic patients
with high-grade carotid stenosis. North American Symptomatic
Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1991 Aug
15;325(7):445-53.
NASCET Results
NASCET Results
NASCET Results
Asymptomatic Carotid
Atherosclerosis Study (ACAS)
Multicenter, randomized, prospective
Medical management vs. medical management & CEA
Asymptomatic patients with 60% ICA stenosis
Endpoints: stroke or death
Results: stroke / death (at 5 years)

Medical Group: 11%
Surgical Group: 5.1% (53% RRR; P = .004)
Surgical Morbidity / Mortality: 1.5%
Major Angio related Morbidity / Mortality: 1.2%
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for
asymptomatic carotid artery stenosis. JAMA. 1995 May 10;273(18):1421-8.
Carotid Revascularization
Endarterectomy vs. Stenting
Trial (CREST)
Multicenter, randomized, prospective, 2502 patients
CEA vs. CAS
Symptomatic patients with ICA stenosis
50% on angio
70% on US
70% on CTA or MRA (if US 50-69% on US)
Asymptomatic patients with ICA stenosis
60% on angio
70% on US
80% on CTA or MRA (if US 50-69% on US)
Endpoint: periprocedural (randomization to ~1 month postop)
stroke, MI, death OR ipsilateral stroke up to 4 years
Trial (CREST)
CAS
CEA
P-value
Overall Endpoints
7.2%
6.8%
0.51
Stroke/death
6.4%
4.7%
0.03
Symptomatic
stroke/death
8.0%
6.4%
0.14
Asymptomatic
stroke/death
4.5%
2.7%
0.07
Periproc. Endpoints
5.2%
4.5%
0.38
Periproc. Death
0.7%
0.3%
0.18
Periproc. Stroke
4.1%
2.3%
0.01
Peroproc. MI
1.1%
2.3%
0.03
Postproc. Ipsilateral
Stroke
2.0%
2.4%
0.85
Periproc. Cranial Nerve
0.3%
4.7%
0.07
Trial (CREST)
Periprocedural Stroke more likely after CAS

MI more likely after CEA
QOL worse after stroke compared to MI
Younger (<70 years) patients had slightly fewer events after CAS
Older patients had fewer events after CEA
More cranial nerve injuries with CEA
Postprocedural stroke similar clinical durability - CREST following out 10 yrs.
Q
7
A 45-year-old woman undergoes angiography for
severe hypertension, as shown. Which of the

following statements about the lesion(s) shown is
TRUE?
A. The most likely etiology is atherosclerosis

B. Lesions > 2.0 cm are associated with a high incidence
of rupture
C. The most common location is in the main renal artery
D.Surgical repair improves control of hypertension in 60%
of patients
E. Lesions < 2.0 cm should be managed nonoperatively
Q
7
A 45-year-old woman undergoes angiography for
severe hypertension, as shown. Which of the

following statements about the lesion(s) shown is
TRUE?
A. The most likely etiology is atherosclerosis

B. Lesions > 2.0 cm are associated with a high incidence
of rupture
C. The most common location is in the main renal artery
D.Surgical repair improves control of hypertension
in 60% of patients
E. Lesions < 2.0 cm should be managed nonoperatively
aneurysm of the renal artery

0.09% of the general population
incidental
most common etiology arterial fibrodysplasia
underlying arterial matrix disruption leads to aneurysm formation, particularly at branch

points where discontinuities in the internal elastic lamina are common, even in healthy
patients
Multiparous women
During the latter stages of gestation, an alteration in hormone and enzyme activity contributes to
the tissue relaxation necessary for parturition. Sustained release of these matrix-altering
substances
35-year experience with 252 renal artery aneurysms in 168 patients at the
University of Michigan, most asymptomatic, average size 1.5 cm
60% of patients undergoing repair had a significant decline in blood pressure
postoperatively, while taking fewer antihypertensive medications
Late renal artery rupture did not occur in the nonoperative patients, but this
group saw no change in their hypertension
average number of renal artery aneurysms per patient was 1.5. Most patients
had solitary aneurysms, but 53 had multiple renal artery aneurysms. Bilateral
aneurysms occurred in 32 patients
The most common location - bifurcation or the first order renal artery branch
not main renal artery itself.
Lesions > 2 cm in diameter are not associated with a higher incidence of
rupture compared with lesions < 2 cm
In fact, patients with aneurysms < 2 cm in diameter can have a significant
improvement in their hypertension and should be offered surgical resection
Most aneurysms 1.5 to 2 cm in diameter and all those larger than 2 cm in
diameter, regardless of blood pressure status, should be treated surgically if
their anatomic characteristics suggest a relatively noncomplex renal artery
construction and the procedure is undertaken by an experienced surgeon
Q
7
Q4
Question: what nerve is entrapped in carpal tunnel syndrome?
Median nerve
Question: most common cause of carpal tunnel syndrome?

other causes?
idiopathic
overuse syndrome
May be seen in conjunction with:

- Colles or Smith's fractures
- rheumatoid arthritis
- gout
- diabetes
- hypothyroidism
- amyloidosis
Q5
Question: What is the most frequently injured carpal
bone?
scaphoid
Question: What is the classic presentation of a

scaphoid fracture?
tenderness in anatomical snuffbox
A 65-year-old diabetic woman has an ulcer

on her toe, as shown. Which of the
A. Percutaneous angioplasty has no role in
the management of this patient
B. The presence of palpable pulses
effectively excludes the diagnosis of
significant arterial occlusive disease
C. Arterial bypass will prevent amputation
D. The patency of the vessels in the foot will
be greater than in the calf
E. The location and number of arterial
stenoses predict primary amputation
Q2
6
A 65-year-old diabetic woman has an ulcer

on her toe, as shown. Which of the
A. Percutaneous angioplasty has no role in
the management of this patient
B. The presence of palpable pulses
effectively excludes the diagnosis of
significant arterial occlusive disease
C. Arterial bypass will prevent amputation
D.The patency of the vessels in the foot
will be greater than in the calf
E. The location and number of arterial
stenoses predict primary amputation
Q2
6
Q2
A recent study of 104 patients with diabetes
mellitus and foot ulcers who were evaluated with 6
arteriography
arterial stenosis or occlusion in 103 patients
Significant stenoses were found in patients with
palpable foot pulses and normal ankle brachial
indices
popliteal and infrapopliteal region
vessels in the foot relatively spared
Nearly 25% of patients could be treated with
percutaneous angioplasty to improve wound
healing and 10% required arterial bypass
procedures
Technical failures occurred in 15% of angioplasty
and in 25% of bypass procedures
limb salvage was achieved in 78% of patients with
44% requiring amputation of single or multiple
digits.
A 78-year-old man who has a 6month history of weight loss and

postprandial pain develops the
abrupt onset of severe abdominal
pain. The lateral aortogram
shown is obtained.
about this condition is TRUE?
A. The prognosis is better than for
mesenteric venous thrombosis
B. Mortality is greater than 75%
C. Survival rates have improved
over the last 40 years
D.Prognosis is independent of the
etiology of the ischemia
E. This disease is usually diagnosed
early in its course
Q3
0
A 78-year-old man who has a 6month history of weight loss and

postprandial pain develops the
abrupt onset of severe abdominal
pain. The lateral aortogram
shown is obtained.
about this condition is TRUE?
A. The prognosis is better than for
mesenteric venous thrombosis
B.Mortality is greater than 75%
C. Survival rates have improved
over the last 40 years
D.Prognosis is independent of the
etiology of the ischemia
E. This disease is usually diagnosed
early in its course
Q3
0
no filling of the superior mesenteric

or inferior mesenteric arteries
Late filling of the celiac artery 2 cm
distal to the origin
Quantitative analysis of 45
observational studies of 3692
patients
venous thrombosis 32% mortality
arterial emboli 54%
nonocclusive ischemia 72.7%
acute arterial thrombosis 77.4%
Q3
0
Q6
Question: What are Kanavel's four signs of flexor
tenosynovitis?
Rest
Splint
1) flexed posture of affected digit

Steroid
injection
2) tenderness along the sheath with erythema
3) pain on passive extension of DIP joint
Surgery
4) fusiform swelling (sausage-like finger)
Q7
Question: Which nerve is injured in anterior

dislocations of the
humerus?
axillary nerve
Q8
Question:
What is a Jefferson fracture?
what type of injuries cause
this fracture?
burst fracture of anterior and

posterior arch of C1
- lateral displacement of
lateral masses of C1
- usually an axial load injury
Question: What is a Hangman's fracture?

bilateral fracture of lateral masses of C2
Q9
Question: What is a Chance

fracture?
transverse fracture through body

of L3
-often seen in drivers with

improperly applied lap belts
-associated with small bowel
injury in 50%
- many recommend laparotomy
for any pt with this fracture
Q1
0
The most appropriate initial

management for a posterior hip
dislocation would be
computed tomography (CT) to evaluate
for intra-articular fragments prior to
reduction
A.conscious sedation with closed
reduction as soon as possible
B.placement of a traction splint
C.bed rest and application of skeletal
traction to reduce the dislocation
D.immediate operative reduction
Q4
3
Q4
The most appropriate initial management 3
for a posterior hip dislocation would be

computed tomography (CT) to evaluate for
intra-articular fragments prior to reduction
A.conscious sedation with closed
reduction as soon as possible
B.placement of a traction splint
C.bed rest and application of skeletal
traction to reduce the dislocation
D.immediate operative reduction
E.computed tomography (CT) to evaluate for
intra-articular fragments prior to reduction
Hip dislocation is often caused by a force applied to the femur Q4

and is most commonly associated with fractures of the
3
acetabulum or femoral head
Motor vehicles crashes are a common mechanism
Force applied to an abducted hip can result in anterior
dislocation
striking the knee on the dashboard with the hip flexed and
adducted results in posterior dislocations
Posterior dislocations often associated with fractures of the
posterior wall of the acetabulum
Once the hip has been completely dislocated posteriorly, it
may appear shortened and internally rotated
Sometimes femoral head or acetabular fractures are
associated with this dislocation
Sciatic nerve injuries are present in up to 15% of posterior hip
dislocations
Closed reduction is usually accomplished by longitudinal
traction, followed by gentle abduction and external rotation
Stability of the reduction should be determined at the time of
closed reduction
Open reduction and internal fixation is indicated only if the
reduction is unstable and associated with a posterior wall
fracture
Question: why is it so
important to not miss a scaphoid
fx?
proximal scaphoid receives its

blood supply from the distal bone
- a missed fx can lead to
avascular necrosis of proximal
scaphoid
Q1
1
Q3
Question: what is a felon?
infection of the pulp of the fingertip that can

lead to deep ischemic necrosis because of
compartmentalizing septa
- pulp space should be drained by
dividing
septa
Question: what is paronychia?
infections around margins of nail plate

- caused by hangnails, manicure
trauma,
small foreign bodies
- usually Staph A.- treat early cases w/
warm soak, abx, drain abscesses
Q3
Felon
Paronychia

ABSITE REVIEW: Vascular Cranial Nerves and Leg Ulcers

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ABSITE REVIEW: Vascular Cranial Nerves and Leg Ulcers

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ABSITE REVIEW

Vagus nerve (hoarseness)

Question: What happens if you cut the Ansa Cervicalis

Blood supply from ECA

A 58-year-old man has multiple sores on his right lower leg, as

A 58-year-old man has multiple sores on his right lower leg, as

Please view the

Please view the

Please view the

Please view the

Please view the

Please view the

38 is the normal anatomy of the right

A 53-year-old man has a 1-week history of a painful blue Q

A 53-year-old man has a 1-week history of a painful blue Q

thromboembolic complication from a large popliteal

Vascular stent-graft - stents at the knee in a younger person

A 28-year-old female body builder has the acute

Brachial plexus &

Thoracic Outlet Exam

Question: Which nerve/artery is commonly injured with

Foot ulcers occur in 15% of all patients with diabetes

underlying sinus tracts or abscesses

mixed infections - broad-spectrum antibiotisc

MRI sensitive and specific indicator of true bone marrow

amputation presents with fever, chills, fatigue, malaise,

amputation presents with fever, chills, fatigue, malaise,

clinically infected, gangrenous transmetatarsal

A.In the absence of antithrombin III, unfractionated heparin

A.In the absence of antithrombin III, unfractionated

Unfractionated heparin - indirect thrombin inhibitor Q

low molecular weight heparins - inhibition of factor

Warfarin - inhibits vitamin K-dependent terminal

Hirudin - direct thrombin inhibitor

A. Elective operation should be considered for patients with

A. Elective operation should be considered for patients with

The mortality of untreated rupture of abdominal aortic Q1

Patients undergoing endograft repair of AAA must be

annual risk of rupture 4.5-cm AAA in a 75-year-old man

Question: Which nerve/artery is commonly injured with

A.Five-year survival is > 90%

A.Five-year survival is > 90%

claudication derived from the root word "to limp

marker for patients at risk of future adverse

The 5-year mortality 30% to 50%, due to

Ankle : Brachial index (ABI)

normal 0.9 to 1.2

The initial recommended treatment for symptomatic mesenteric

The initial recommended treatment for symptomatic mesenteric

Which of the following has the most important

Which of the following has the most important

The most likely adverse event associated with occlusion of the

The most likely adverse event associated with occlusion of the

Endovascular Repair of an Abdominal Aortic Aneurysm, with the Use of an Endograft

Greenhalgh R and Powell J. N Engl J Med 2008;358:494-501

The 5 Types of Leakage of Blood into the Aneurysm, or Endoleak

The Four Types of Leakage of Blood into the Aneurysm, or Endoleak

Greenhalgh R and Powell J. N Engl J Med 2008;358:494-501

A. chronic oral anticoagulation

Open surgical techniques such as subclavian-jugular bypass or

Five days after an uncomplicated right carotid

A. administration of intravenous heparin

Five days after an uncomplicated right carotid