Vascular

Carotid/Vertebral

• What are the structures of the carotid sheath?
• Carotid Artery
• Internal Jugular Vein
• Vagus Nerve
• What are the segments of the vertebral artery?
• V1 - Origin off subclavian to foramina of C6
• V2 (Foraminal) - From the transverse foramen of C2-C6
• V3 - From C2 to Dura
• V4 - Intracranial
• What is the structure commonly overlies the carotid artery bifurcation?
• Facial vein off of IJ generally overlies the bifurcation
• What is the first branch of the external carotid artery?
• Superior thyroid artery
• Is the external carotid artery flow high or low resistance ?
• It is high resistance (flows to muscular facial muscles), so triphasic flow on doppler, brief reversal of flow
• Can the external carotid artery be ligated?
• External carotid can be tied off to help control excessive facial bleeding in trauma
• Internal carotid artery main blood supply to brain, first branch is the ophthalmic
• Low resistance as it is supplying brain tissue, so it has continuous forward flow which creates a biphasic doppler signal Doppler of the internal carotid is biphasic with a long diastolic phase, distinctly different than the high resistance of the triphasic external carotid

Figure 1. Carotid Bifurcation Anatomy

• Hoarseness after carotid endarterectomy?
• Likely injury to vagus nerve
• From clamping the carotid the vagus nerve was also clamped
• Tongue deviation to side of injury?
• Likely hypoglossal nerve injury
• Nerve lies just cephalad to carotid bifurcation so can easily be damaged
• Ipsilateral mouth droop after a carotid?
• Marginal mandibular injury
• From retraction on mandible, generally when trying to expose high lesions
• This nerve lies deep to posterior belly of digastric and if divided can cause disabling dysphagia .

• Glossopharyngeal

• What layers of carotid are removed during an endarterectomy?
• Intima and part of the media
• What is the typical location of carotid atherosclerosis?
• Carotid bifurcation due to turbulence
• Indications for performing carotid endarterectomy
• Symptomatic (stroke or TIA), 50-70% warrants surgery
• Asymptomatic - controversial if over 80% or EDV (end diastolic velocity) > 140 cm/s (which correlates with 80% stenosis)
• Should start with medical management aspirin and a statin
• What if patient is symptomatic but duplex shows <50% stenosis?
• No surgery indicated
• Optimize medical management - aspirin, Plavix and a statin
• What if patient has a stroke and imaging shows a completely occluded carotid artery?
• Anticoagulation to prevent progression, no benefit to recanalizing
• What situations would an emergent carotid endarterectomy be indicated
• Crescendo TIAs
• TIA symptoms are recurring and becoming more severe or lasting longer in duration
• What is the most common non stroke cause of morbidity and mortality after CEA
• Myocardial infarction
• When should you operate on a symptomatic carotid
• Small stroke or TIA - within two weeks once symptoms resolve

• Hemorrhagic stroke - 6-8 weeks

• What if patient demonstrates symptoms of stroke in PACU after carotid endarterectomy
• Return to OR to evaluate for intimal flaps or thrombus
• In OR start with US
• Which clinical scenarios would you consider carotid stenting over carotid endarterectomy
• Hx of neck dissection, neck irradiation, recurrent carotid disease
• Severe cardiac disease TCAR (Transcarotid Artery Revascularization) or transfemoral stenting should be considered in patients with previous neck surgery or radiation. TCAR has lowest stroke rate. Non-Atherosclerotic Carotid Lesions
• A patient s/p blunt trauma and is found to have asymptomatic carotid dissection
• Should be anticoagulated (either heparin or Plavix, not standardized)
• Repeat imaging before leaving hospital
• A patient s/p blunt trauma and found to have a symptomatic dissection
• Will likely require a covered stent
• A patient s/p blunt trauma with traumatic occlusion of carotid artery
• If already have neurologic injury/completed stroke unlikely to get better with intervention
• Antithrombotic therapy
• Carotid body tumors
• All require resection
• Consider embolization prior to surgery due to risk of bleeding

Subclavian/Thoracic Outlet

• Name the structures of the thoracic outlet anterior to posterior
• Subclavian vein
• Phrenic nerve
• Anterior scalene
• Subclavian artery
• Middle scalene
• First Rib
• What anatomic anomaly puts patients at risk for thoracic outlet syndrome?
• Cervical rib
• Where is brachial plexus found in the thoracic outlet?

• The brachial plexus is along the middle scalene, posterior to the subclavian artery Figure 2. Thoracic Outlet Anatomy

• Which type of TOS is most common, and what are the classic symptoms?
• Neurogenic (95%)
• Pain, weakness, numbness and tingling in the hand, particularly in ulnar distribution
• Symptoms worse with manipulation/elevation of arm
• Treatment of neurogenic TOS?
• Physical therapy is go to method
• If PT fails confirm diagnosis with scalene block or nerve conduction test
• First rib resection and scalenectomy with neurolysis is operation of choice for refractory neurogenic TOS
• A swimmer presents with a blue swollen arm, what is this and how do you treat it?
• Subclavian Vein Thrombosis (Paget-Schroetter), compression at costoclavicular junction
• Treat with catheter directed thrombolysis followed by first rib resection within the same hospital stay or shortly after
• A young person with no atherosclerotic risks factors presents with ischemia of the hand
• Common presentation for arterial TOS, though arterial TOS is very rare
• Likely an anomalous cervical rib is compressing the subclavian artery and will lead to an aneurysm, which is an embolic risk
• Will need first rib resection with interposition graft for the artery Subclavian Steal Syndrome
• Where is the anatomic stenosis that results in subclavian steal?
• Proximal subclavian narrowing

• Results in a reversal of blood flow in vertebral, which can lead to vertebrobasilar symptoms

• Symptoms occur when extremity is exerted and it steals blood from cerebral circulation
• How do you fix it?
• Endovascular recanalization and stenting or potentially carotid subclavian bypass are subclavian transposition Dialysis Access
• How long should a temporary catheter be left in place (called Vas-Cath at many places) and why do they need to be removed?
• 3 weeks
• Infection risk
• How do long term tunneled catheters differ (Permacath)
• They are cuffed
• They are tunneled
• Lower risk of central infection
• Still higher infection rate, and high risk of central venous stenosis compared with fistula or graft
• What is preferred location for temporary dialysis access and what should be taken into account?
• Right IJ direct to right atrium
• Avoid the side where you plan to place permanent AV Fistula
• Will cause central venous stenosis, will lead to failure of permanent access
• What is preferred location for AV fistula creation for dialysis access?
• “Fistula First” Always start distal on non-dominant arm, and upper extremities before lower extremities, Start distal to not burn bridges .
• Reducing catheter days, improves life expectancy

• Focus is now moving to choosing the right access for the right person, a person with a short life expectancy, a fistula may not be the best access

• What is the most common reason for AV fistulas to malfunction over time?
• The major cause of hemodialysis AV access failure is venous outflow problems.
• A patient reports that she is having high venous return pressures, and increased bleeding after dialysis, what is the likely problem, how do you diagnose it and what is the treatment?
• Likely has venous outflow stenosis
• Can be diagnosed with duplex US
• Fistulogram with balloon angioplasty can likely correct the lesion
• What are criteria for fistula maturation, “Rule of 6s”?
• Needs to be 6 mm in diameter
• <6 mm deep

• 600 mL/min in flow

• 6 weeks after a brachio-cephalic fistula creation, the fistula fails to mature, what are some likely causes of this and how can they be managed?
• Possible inadequate inflow, rule out stricture at anastomosis, potential balloon angioplasty vs revision of anastomosis
• Competing flow from side branches, branches need to be ligated or coiled A bleeding fistula with pinpoint hole bleeding can be treated with a stitch and urgent fistulogram. Bleeding from an ulcer on a fistula is a surgical emergency.

Fasciotomies

• When are fasciotomies indicated? What are the symptoms?
• In a patient with documented lower extremity compartment syndrome
• A patient that had acute limb ischemia for > 4 hours, should be considered for prophylactic fasciotomy
• Patients will have tight compartments, pain with passive motion of foot
• Where to make incision to access anterior and lateral compartments?
• Make incision lateral to tibia in between the tibia and fibula (H type incision to pen both anterior and lateral compartments, incisions should be anterior and posterior to intermuscular septum .
• What nerve can you injure with the lateral incision and what deficit would you see?
• Superficial peroneal nerve which can lead to difficulties with foot eversion .
• To access superficial posterior and deep posterior compartments?
• Make incision two centimeters posterior/medial to tibia
• The key to perform a complete four-compartment fasciotomy is to make sure that the posterior deep compartment has been fully decompressed. Both the superficial and the deep posterior compartments are decompressed through the medial incision .
• How do you release the deep posterior compartment?
• Take soleus off of the tibia . Thoracic Aorta
• In a blunt thoracic aortic injury, where is the most common site of injury?

• Just distal to subclavian artery in the descending thoracic aorta, at the level of the ligamentum arteriosum, the aorta is tethered here

• A pseudoaneurysm develops here (partial transection)
• Treated with TEVAR
• What are the size criteria for treating descending thoracic aortic aneurysms?
• If endovascular repair is possible if > 5 .5 cm
• Otherwise aorta should be > 6 .5 cm
• What is a feared complication of thoracic aorta repairs?
• Paraplegia (<5% for endovascular vs 20% for open)
• Reduce this risk by placing lumbar drains and increasing the blood pressure
• Spinal Perfusion Pressure = MAP (drive up with pressors) - ICP (lower with spinal drain) Abdominal Aorta/Aneurysms
• Acute mesenteric ischemia has 4 types
• Embolic
• Thrombotic
• Venous thrombosis
• Non occlusive mesenteric ischemia
• Which is most common type of mesenteric ischemia and how do you diagnose and treat it
• Embolic is most common, likely from afib or endocarditis
• Patients will have severe abdominal pain, with no other supporting findings on exam (pain out of proportion to exam)
• CTA is best modality to diagnose
• Heparinize the patient and take to OR for ex lap and SMA embolectomy
• Best to leave abdomen open and re-explore in 12-24 hours before resecting any marginally perfused bowel
• Which type is most common in a patient that has severe atherosclerotic disease burden?
• Thrombotic disease

• This likely occurs at ostium/takeoff of the SMA

• Embolic disease is more distal, generally at first branch of SMA
• Pts with thrombotic AMI, likely have had unrecognized symptoms for months - years
• These patients will likely require a mesenteric bypass rather than embolectomy
• Which disease process embolic vs thrombotic will have proximal jejunal sparing?
• Embolic because it lodges just distal to first branch of SMA (3-10 cm distal to ostium)
• Thrombotic patients will not have any sparing of small intestine
• How do you identify the SMA to perform embolectomy?
• Lift transverse colon cephalad and follow to base of transverse mesocolon
• Just to the right of Ligament of Treitz (LOT) will be the SMA
• Mobilize LOT to access SMA at its origin
• What are characteristics of mesenteric venous thrombosis
• Sub-acute, multiple days of abdominal pain and bloody diarrhea
• Generally have an underlying hypercoaguable disorder
• CTA will demonstrate small bowel wall thickening, mesenteric edema, and thrombosis of SMV
• Heparinize patients, rarely need surgery, only for resection of ischemic bowel
• What are characteristics of NOMI?
• Patients are generally critically ill, on multiple pressors and many times have cardiac failure
• Ischemia is in watershed areas (splenic flexure and upper rectum)
• Treatment is resuscitation and improvement of cardiac functions
• Only OR if need to resect ischemic bowel

Figure 3. Abdominal Vascular Anatomy Quick Hits

• What is most common site for a upper extremity embolus to lodge? - Brachial artery at bifurcation of radial and ulnar artery

• What is most common site for a lower extremity embolism to lodge - Common femoral artery at bifurcation of profunda and SFA

• In a patient with a ruptured AAA with hypotension that is getting a crash laparotomy . Where should you get proximal control?
• Supraceliac aorta through the gastrohepatic ligament, underneath crus of diaphragm, press aorta against spine
• A patient that has a ruptured AAA that is being transferred to you, what do you tell the outside center to keep his BP at?
• Permissive hypotension keep SBP 80-100
• MC organism in graft infections is?
• Staph epidermidis (slow insidious bug)
• Treatment for popliteal entrapment syndrome?
• Resect medial head of gastrocnemius
• What if a patient has refractory HTN and is found to have a beads on a string appearance in renal arteries or has same angiographic finding on internal carotids?
• Fibromusclar dysplasia, most common in renal arteries and balloon angioplasty is treatment method of choice . Also seen in carotids Aneurysms Continued…
• What is the most common splanchnic aneurysm and indications for operating on it?
• Splenic artery
• Operate on if >2 cm, or if pt is pregnant
• Most can be coil embolized
• If unstable perform splenectomy
• What is the clinical presentation of a ruptured splenic artery aneurysm?
• “Double Rupture”, due to containment by the lesser sac, and then free intraperitoneal rupture

• What size criteria should you treat hepatic and SMA aneurysms?

• Treat when they reach 2 cm in size
• Treat with resection and reconstruction
• What size criteria for treating iliac artery aneurysms?
• Commonly associated with abdominal aortic aneurysms
• 3 .5 cm is size criteria for repair
• Generally repaired with endovascular stents
• What is the size criteria for treating femoral artery aneurysm, and what is most likely complication of femoral artery aneurysm?
• 2 .5 historically but can be observed up to 3 .5 cm
• Unlikely to rupture more likely to cause embolus or thrombosis
• Treat with resection and interposition
• Size criteria for treating popliteal artery aneurysms, what workup does patient need?
• 2 cm or if symptomatic (Embolic source or thrombosis)
• Pts need work up for AAA
• What are options for treating popliteal artery aneurysms
• Exclude and bypass or interposition with vein is the gold standard
• Endovascular stents are reasonable if patient is not a good candidate for open surgery
• Indications for operating on abdominal aortic aneurysms

• 5 .5 cm in males or > 5 cm in females

• If growth > 1cm/year
• If symptomatic or infected (mycotic)
• When performing an open AAA repair when do you re-implant the IMA?

• If back pressure is poor or less than 40 mmHg

• If pulsatile back bleeding collateral flow is adequate, if minimal colon likely requires the additional flow from aorta
• If colon appears dusky or they had previous colonic surgery
• Disrupts collateral blood flow such as Arc of Riolan or Marginal Artery of Drummond Recognizing and managing complications is the most important aspect for ABSITE and oral boards.
• What vein is at risk for injury in an open AAA when clamping aorta proximally?
• A retro-aortic left renal vein can be injured and cause significant bleeding
• Important to evaluate for this on preoperative imaging
• Patient develops painless abdominal distention after starting a diet following an open AAA repair . Fluid is seen and tapped and noted to be milky, what is this condition called and how do you treat?
• Chylous Ascites
• Low fat, high protein diet with medium-chain fatty acid supplementation
• A patient after an open AAA repair develops abdominal pain and bloody diarrhea . What are you concerned for and what is algorithm to treat this condition?
• Sigmoidoscopy to diagnose, along with starting IVF and IV abx
• Many times can be managed nonoperatively, but if patients develop peritonitis, sepsis, or frankly necrotic colon seen on sigmoidoscopy they need an emergent colectomy with Hartman’s pouch
• Which part of large intestine is spared from ischemia after AAA induced colonic ischemia

• Middle and distal rectum as they have separate blood supply from sigmoid/upper rectum

• Blood supply is from internal iliacs not IMA
• A pt is identified with a 4 cm abdominal aortic aneurysm how do you want to follow it
• Yearly duplex US if aneurysm is 4 cm or less
• If greater than 4 will need at least every 6 month duplex
• If you diagnose an infrarenal aortic graft infection, what is treatment of choice?
• -Axillary to bi-femoral bypass with aortic graft excision
• When you perform an aorto-bifemoral bypass how do you decide between end to end aortic anastomosis vs end to side anastomosis?
• Need to ensure flow into at least 1 internal iliac for pelvic perfusion
• If external iliacs are patent can perform end-end as patient will have internal iliac perfusion from retrograde flow
• If external iliacs are not patent can perform end-side anastomosis which will allow antegrade flow into internal iliacs assuming common iliacs are patent
• What anatomic criteria are needed to perform an EVAR?
• Neck diameter less than 32 mm
• A neck angle less than 60 degrees
• A neck length of at least 10 mm
• Iliac diameters of at least 7 mm
• Lack of thrombus or calcification in infrarenal neck
• What are the types of endoleaks and treatment options for each
• Type 1 (a proximal, b for distal)
• Means the endograft isn’t sealed at proximal or distal end point
• These must be fixed, as risk of rupture

• Generally place a cuff to seal more proximally or distally

• Type II
• Lumbars or IMA continue to fill aneurysm sac
• Only need to be fixed if aneurysm sac continues to grow
• Coil embolization of lumbars feeding sac is best treatment option
• Type III
• Components of the endograft are not sealed
• Must be fixed, as aneurysm sac will be pressurized
• Reinforce with cuff across previous interlap between components
• Type IV
• Porosity of graft, or a tear in the graft
• May need to reline the graft with new endograft Peripheral Vascular Disease
• How do you calculate an ABI?
• Take which ever pedal pressure is the highest (DP or PT) and divide that by the highest brachial pulse (right or left arm)
• How to interpret an ABI?
• .9 → 1 .4 is normal

.5 → .89 may have claudication

<0 .5 = May have rest pain

<0 .3 = Tissue loss

• What if patient has non compressible vessels, can you rely on ABIs?
• No small vessel calcification will lead to falsely elevated ABIs

• Toes pressures should be obtained, as these vessels are generally free from calcification

• A patient presents with claudication, how do you treat them?
• Smoking cessation, exercise, statin therapy
• What indications would you intervene on a patient with claudication
• Lifestyle limiting claudication that failed improvement with medical management
• Tissue loss
• Rest pain High yield! Do not offer operation for claudication, unless failed medical management and severe lifestyle impairment
• What options are there for imaging blood vessels
• CTA is good for proximal vessels to level of knee if kidney function ok
• If not angiography can use less contrast and visualize tibial vessels better
• Also can do C02 angiography if very poor renal function
• MRA is also an option
• What are essentials of operative planning in vascular surgery?
• Inflow, outflow and vascular conduit (if bypass)
• What are principles of deciding between treating a lesion endovascular vs open
• In general, endovascular interventions are best suited for lesions that are short and not heavily calcified.
• Long occlusions that are densely calcified with good inflow, outflow and conduit are likely better treated with open bypass vs endarterectomy .

• The common femoral artery is rarely treated with an endovascular approach because it is a mobile area that is prone to kinking and also because of the relative ease of an open approach .

• A patient presents with buttock claudication, impotence, and absence of femoral pulses, what is this syndrome called and where would you expect the lesions to be?
• Leriche Syndrome
• Aorto-iliac symptoms
• Patient likely needs an aorto-bifemoral bypass
• If a patient presents with a large acute embolus that lodges at the aortic bifurcation, how does this differ in regards to treatment options compared to Leriche Syndrome?
• Embolic disease can be treated with bilateral transfemoral retrograde embolectomy
• Leriche syndrome is an atherosclerotic disease process for which a bypass would be indicated
• A pt presents with thigh claudication, where would you expect the lesion to be?
• Iliac lesion
• A pt presents with calf claudication, where would you expect this lesion to be?
• SFA
• Know basic anatomy of angiogram
• You will have your anterior tibial artery branching first and going through intermuscular septum, you will then have tibial peroneal trunk, with peroneal coursing posterior to fibula, and posterior tibial doing just that, traveling behind the tibia
• What are the four compartments of the lower leg? And what do they contain
• Anterior and lateral released with lateral fasciotomy incision
• Anterior contains anterior tibial artery
• Lateral compartment contains superficial peroneal nerve
• Superficial and deep posterior
• Superficial contains the gastrocnemius and sural nerve

• Deep contains the tibial nerve, posterior tibial artery, and peroneal artery

• What vessels does diabetes damage?
• Tibial vessels and small vessels of the feet
• In a patient with a diabetic foot wound, what imaging modality is the most sensitive for osteomyelitis?
• MRI
• How to manage a diabetic foot ulcer with osteomyelitis in underlying bone?
• Debride to healthy bone and then prolonged antibiotics 4-6 weeks .
• In any patient with a foot wound it is important to make sure adequate perfusion, how is this done
• Start with non invasive flow studies (NIFs) and ABIs
• If these show flow that is impaired the patient needs an angiogram that can be both diagnostic and therapeutic Venous Disease
• How do operatively approach the left common iliac vein
• By dividing the overlying right iliac artery, if the vein needs to be accessed and repaired
• What veins can be ligated in trauma
• Can ligate any vein distal to renal veins
• The closer to the renal veins the more morbidity, but if it is for exsanguinating hemorrhage it can be considered
• If major vein ligation consider prophylactic fasciotomy
• Can you divide either renal vein?
• You can divide the left renal vein if it is proximal to gonadal vein and gonadal vein is intact to allow retrograde drainage

DVT Management

• A pt has a swollen blue leg up to the buttocks, with motor and sensation intact, what are you worried about and what is the treatment?
• Ileofemoral DVT causing phlegmasia cerulea dolens
• Catheter directed thrombolysis is the treatment
• What is the most common location of DVTs? Which leg has a higher rate?
• Ileofemoral DVTs are most common
• Left leg is 2x more common than right
• Where should an IVC filter be placed in relation to the renal veins
• Distal (caudad) to the renal veins
• How to long anticoagulate after a DVT
• Provoked DVT = 3 months of therapy
• Active Cancer = Continue therapy until no longer have cancer/cured
• Hypercoaguable disorder = lifelong therapy Quick Hits
• How to access SMA in trauma?
• Exposure to SMA is by lifting of transverse colon and mobilizing ligament of treitz
• How to expose supraceliac aorta in trauma?
• Enter lesser sac through gastrohepatic ligament, can divide posterior crus of diaphragm
• What is the biggest risk factor for ischemic colitis in a patient with a ruptured aneurysm?
• Preoperative hypotension

• Old lady with headaches, and temporal blindness and fatigue, what is it and how do you treat?

• Temporal arteritis
• Diagnose with a temporal biopsy
• Treat with corticosteroids
• What vessels are effected in Buerger’s disease?
• Small to medium sized vessels
• Mycotic aneurysms what is the most common organism?
• Staphylococcus (not salmonella)

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