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Vascular

1- ischemic leg:
a) golden periods 4-16 hrs
b) nerves are first structure to be damage
c) angiogram is done in all pt
d) parasthesia pts are more critical than those with pain
2- Below the inguinal ligament, where is the femoral artery
a) medial
b) lateral
c) anterior
d) posterior
e)midpoint
3- Varicose veins will affect all the following except :
a)short saphenous vein.
b)long saphenous veins.
c)popliteal vein
deep vein
d)perforaters.
-Varicose vein can be in all veins, EXCEPT:
a) Long saphenous vein
b) Shod saphenous vein
c) Poploteal vein
d) Perforators
Varicose veins and spider veins are normal veins that have dilated under the influence of increased
venous pressure.
4-Multiple ulcers on the medial aspect of the leg with redness and tenderness around it are
most likely:
a) Venous ulcers.
b) Ischemic ulcers. Pale ulcers
c) Carcinoma.
5- All can complicate excision of abdominal aortic aneurysm, except:
a) Paraplegia
b) Renal failure
c) Hepatic failure
d) Leg ischemia
Presentation
 Asymptomatic: Most patients present without an asymptomatic pulsatile abdominal mass (see Image 5). The
aortic bifurcation is located just above the umbilicus. Occasionally, an overlying mass (pancreas or stomach)
may be mistaken for an AAA. An abdominal bruit is nonspecific for a nonruptured aneurysm. Patients with
popliteal artery aneurysms frequently have AAAs (25-50%).
 Rupture: Persons with AAAs that have ruptured may present in many ways. The most typical manifestation of
rupture is abdominal or back pain with a pulsatile abdominal mass. However, the symptoms may be vague,
and the abdominal mass may be missed. Symptoms may include groin pain, syncope, paralysis, or flank mass.
The diagnosis may be confused with renal calculus, diverticulitis, incarcerated hernia, or lumbar spine disease.
 Peripheral emboli: Atheroemboli from small AAAs produce livedo reticularis of the feet or blue toe syndrome

vomiting. Incomplete valves causing high venous pressure. Hemosiderin deposition. and perioperative monitoring is important. congestive heart failure (CHF). c. palpate femoral popliteal and pedal pulses (dorsalis pedis or posterior tibial) to determine if an associated aneurysm (femoral/popliteal) or occlusive disease exists. Physical examination Bilateral upper extremity blood pressures are discernible in patients with AAAs. Hypertension may trigger a workup for renal artery stenosis. intraoperative cholesterol embolization. d. May be effectively treated with elastic stockings.Less than 1% if elective and 15-20% if ruptured Renal failure related to preoperative creatinine level. AAAs may cause symptoms from local compression. or venous thrombosis from venous compression. Regarding the peripheral pulses. Subcutaneous fibrosis. nausea.2-5% Groin infection . guaiac-positive stool is present with associated colon cancer. machinery-type abdominal bruit.8-5% if elective and 50% if ruptured Pneumonia . abdominal thrill. Are merely a cosmetic problem. Transient hypotension should prompt consideration of rupture because this finding can progress to frank shock over a period of hours. embolic phenomenon to the toes. and peripheral ischemia. Patients may describe a pulse in the abdomen and may actually feel a pulsatile mass. Most clinically significant aneurysms are palpable upon routine physical examination. Require ultrasonography for diagnosis. and the size of the patient.5% Myocardial infarction . renal failure. 7. Lead to ulceration of the skin. Flank ecchymosis (Grey Turner sign) represents retroperitoneal hemorrhage. Are cured for the life of the patient by surgical excision. Bruits may indicate the presence of renal or visceral artery stenosis.  Aortoduodenal fistulae: Finally. Unequal blood pressures (>30 mm Hg) indicate subclavian artery stenosis. Abdominal examination includes palpation of the aorta and an estimation of the size of the aneurysm. Cervical bruits may indicate carotid artery stenosis. Aortocaval fistulae: AAAs may rupture into the vena cava. producing acute claudication. c. . while 62% were detected incidentally based on radiologic studies obtained for other reasons. e. and hypotension Incisional hernia . symptoms include tachycardia.Varicose veins: a. however.10-20% Bowel obstruction Amputation from major arterial occlusion Blue toe syndrome and cholesterol embolization to feet Impotence in males . Most persons with AAAs are asymptomatic. urinary symptoms. Back pain can be caused by erosion of the AAA into adjacent vertebrae. 38% of AAA cases were detected based on physical examination findings.1. With respect to rectal aspects of the physical examination. the sensitivity of the technique is based on the experience of the examiner. d. Transudation of serum proteins. b. and fever. a thrill is possible with aortocaval fistulae. Other symptoms include abdominal pain. e. In a recent study. leg swelling. the size of the aneurysm. These patients may present with a herald upper gastrointestinal bleed followed by an exsanguinating hemorrhage. Temporary loss of consciousness is also a potential symptom of rupture.Erectile dysfunction and retrograde ejaculation (>30%) Paresthesias in thighs from femoral exposure (rare) Lymphocele in groin . At times. an AAA may rupture into the fourth portion of the duodenum.  Acute aortic occlusion: Occasionally. Complications of operation                Death . groin pain. small AAAs thrombose.Less than 5% Graft infection .The key pathology in the pathophysiology of venous ulceration is: a.Less than 1% Colon ischemia . The presence of varicose veins. In this case. producing large arteriovenous fistulae. b. including early satiety.Approximately 2% Late graft enteric fistula 6.

and to determine therapeutic intervention. Spherocytosis. it is now rarely used because of the potential adverse effects.6-phosphate dehydrogenase deficiency. Duplex ultrasonography.1-0. genitalia. Glucose. coagulation. Lymphangiography. Lymphedema is an abnormal collection of protein-rich fluid in the interstitium due to a defect in the lymphatic drainage network. d. Pyruvate kinase deficiency. Venous abnormalities such as deep vein thrombosis can be excluded based on ultrasonography findings. e. e. . or trunk. Ultrasonography can be used to evaluate the lymphatic and venous systems. but it can be used to confirm it. Imaging Studies Imaging is not necessary to make the diagnosis.Splenectomy does not have a role in the management of patients with hemolytic anaemia due to: a. both primary and secondary in nature. affecting blood flow. to assess the extent of involvement. MRI and CT scanning can also be used to evaluate lymphedema.Lymphedema is diagnosed most effectively by: a. These radiologic tests can be helpful in confirming the diagnosis and monitoring the effects of treatment. It allows for detailed visualization of the lymphatic channels with minimal risk. Lymphoscintigraphy is the new criterion standard to assess the lymphatic system. 9.     Lymphangiography is an invasive technique that can be used to evaluate the lymphatic system and its patency.8. A complete history and physical exam. 10-Risk of DVT can be decreased by these measures except: a) discontinue oral contraceptives 7-10 days before surgery b) daily intake of 1mg warfarin for 10 days c) early ambulation after major surgery d) intermittent pneumatic device intraoperative e) administration of Dextran 70 oral contraceptives should be stopped at least 3-4 weeks before surgery Prevention of deep venous thrombosis (DVT) has long been studied in a variety of clinical situations with varying degrees of success. c. Surgical patients undergoing general anesthesia have been extensively studies as described earlier with fatal PE rates ranging from 0. or vessel wall endothelium. b. Although it was once thought to be the first-line imaging modality for lymphedema. They are also recommended when malignancy is suspected. 31 Many different forms of therapy have been evaluated in this group.8% for all patients29. Elliptocytosis. Sickle cell anaemia. The anatomy and the obstructed areas of lymphatic flow can be assessed. have been identified for this condition. Numerous causes. Lymphoscintigraphy. Lymphedema most commonly affects the extremities. b. Primary prophylaxis is directed toward acting on one or more components of the Virchow triad. Volumetric and structural changes are identified within the lymphatic system. but it can involve the face. d. c. Magnetic resonance imaging.30 and up to 7% of patients undergoing surgery for fractured hips. Studies have also addressed the timing for the initiation of prophylaxis and the duration.

Early prophylaxis in surgical patients with LMWH has been associated with significant reductions in postoperative venous thrombosis. Low-molecular weight heparin (LMWH) has been shown to be superior to both heparin and warfarin in high-risk patients such as those suffering from multitrauma and postorthopedic surgery.33 However. the effect is less impressive in higherrisk patients. 38 Additional recommendations by the ACCP for extended out-of-hospital prophylaxis have been made based on multiple randomized studies that have demonstrated an additional 7-10 days of anticoagulation decrease venous thrombosis rates without major bleeding issues. Studies have shown that initiation of therapy within 8 hours of surgery has the greatest effect and is currently recommended by the American College of Chest Physicians. preventing the propagation of clinically important thrombosis with less postoperative bleeding complications. 32. however.7% to 0. Studies in cardiac surgery and neurosurgical patients have shown a distinct improvement in the incidence of deep venous thrombosis (DVT) without the added risk of bleeding. fatal PE was decreased from 0. Therapy is often initiated the night prior to surgery.35 Equivalent results were seen in general surgery patients and medical patients. Anticoagulants represent another form of primary prophylaxis against venous thrombosis that has been extensively studies in recent years. Subcutaneous heparin of 5000 units given twice daily has been shown to not only decrease the incidence of deep venous thromboses (DVTs) but also prevents fatal PE. The effectiveness of heparin has been established by numerous randomized clinical trials.34 Vitamin K antagonists such as warfarin have also been shown to be an effective form of primary prophylaxis in high-risk patients.37 Timing and duration of prophylactic agents has also been determined to have a significant effect the development of deep venous thrombosis. the anticoagulation effects of warfarin do not begin until the third day of use. In one multicenter international trial.Intermittent pneumatic leg compression devices work by effectively increasing venous blood flow and activating the fibrinolytic system. .1%. and compliance can be difficult. 36.