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Week 1- Surgery

 

  1. If this same presentation above except with no history of PAD, no history of smoking, pulses felt throughout LE. What 2 tests would be indicated to rule out other causes of the problem and why? 
    1. I would do a duplex ultrasound to rule out a DVT that has been present for an extended period of time. I feel I would need to rule out this cause before moving on to other differentials. Furthermore, this can help rule out chronic venous insufficiency as well. 
    2. I would also consider a compartment pressure measurement test, to rule out compartment system which does not present very similarly but does have some overlapping symptoms.
    3. PS: An ankle-brachial index could also be useful to establish a diagnosis of PAD, as just because there is no current PAD diagnosis, does not mean that the patient does not have it.
  2. For someone who has chronic arterial disease, progressively worsening without an acute situation like this – what are the three different indications for intervention?
    1. I had some trouble with this question, as when three specific instances were mentioned it did include acute limb ischemia. However, I was able to find another indication in some other sources as a third indication.
      1. Significant, disabling claudication that is unresponsive to conservative measures, such as lifestyle modifications and medical therapy
      2. Chronic limb-threatening ischemia, manifesting with rest pain or ulcers
      3. If the atherosclerotic lesions are focal
  3. Contrast surgical indications with someone who needs intervention for aortic aneurysm, and someone who has carotid artery disease? How is your thinking different? 
    1. An elective aneurysm repair would occur when it is at least 5.5 cm in diameter or has grown rapidly, specifically over 0.5 cm within 6 months. Endovascular repair is preferred for those, such as the elderly, who may be too frail for surgery. Being that rupture carries a very high mortality rate, the decision to intervene is based on increasing risk of rupture.
    2. For carotid artery disease, there is more of a risk vs. benefit analysis, whereas AAA surgery is necessary to prevent a very high mortality event. For symptomatic carotid artery stenosis, carotid endarterectomy is indicated in patients with a minimum of five years of life expectancy who have a lesion that can be accessed surgically, no significant diseases whose risks would outweigh the harms of anesthesia/ surgery, and no history of endarterectomy on the same side. Furthermore, one may elect carotid artery stenting over endarterectomy if the lesion cannot be accessed surgically, the stenosis is a result of radiation, or again, if other comorbidities make the risk of surgery outweigh the benefits.
  4. If one needs intervention for PAD, why would one need surgery and not endovascular intervention (ie. angioplasty, stent)? Hint: Classifications of arterial disease, TASC2 criteria. 
    1. The TASC-2 guidelines are very helpful in classifying the complexity/ severity of lesions and determining the best interventions (endovascular repair vs. surgery). TASC-2 classifies iliac, femoral, and popliteal lesions from A to D, with A and B lesions preferring endovascular repair and C and D lesion preferring surgical repair. However, these guidelines have their limitations as they do not include tibial lesions and cannot be used for multilevel disease.
    2. For those with multi-level disease and under two-year life expectancy, the best initial intervention is balloon angioplasty. If greater than two years, bypass surgery is the preferred initial intervention.
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