Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3742_Библиотеки_им_академика_М_И_Перельмана
.pdf
90 Section 7: Thoracic Outlet Syndrome
RATIONALE 1–8
1. RATIONALE
The thoracic outlet region is composed of three anatomic spaces: The scalene triangle, the costoclavicular space, and the pectoralis minor space. The neurovascular bundle, which consists
of the subclavian artery, subclavian vein, and brachial plexus, courses from the scalene triangle
to the costoclavicular space and through the pectoralis minor space. Neurogenic thoracic
outlet syndrome results from brachial plexus compression, which leads to neurological symptoms involving the upper extremity. Abnormal anatomy of the thoracic outlet region, as well
as injuries and repetitive physical activities, can predispose a patient to the development of
thoracic outlet syndrome. Because of the lack of objective criteria for neurogenic thoracic outlet
syndrome, it is difficult to diagnose this condition. The presence of a cervical rib and a positive
response to scalene muscle block are reliable indicators for surgery. The decompression can be
performed by a supraclavicular or transaxillary approach, depending on the experience of the
surgeon and the manifestation of thoracic outlet syndrome. Most surgeons prefer the supraclavicular approach in the presence of a cervical rib, but excellent results have also been reported
using transaxillary approach even in the presence of the cervical rib. In patients with a cervical
rib requiring thoracic outlet decompression, scalenectomy, and removal of the first rib as well as
the cervical rib are necessary in order to obtain relief of symptoms.
First cerv ical rib, typically connected by a joint.
Correct Answer C Removal of the first rib, scalenectomy, and removal of cervical rib
Reference
Illig, K. A., Donahue, D., Duncan, A., et al. (2016). Reporting standards of the Society for Vascular
Surgery for thoracic outlet syndrome: executive summary. J Vasc Surg, 64(3), 797–802.
PMID: 27565596
2. RATIONALE
Long thoracic nerve injury during decompression of the thoracic outlet may result in paralysis, pain, weakness, and limitation of shoulder elevation. The scapula tends to protrude at an
Section 7: Thoracic Outlet Syndrome 91
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
awkward angle from the body. The patient may benefit from physical and massage therapy
in addition to muscle relaxants and antiinflammatory drugs. Decompression of the thoracic
outlet can be performed by either a supraclavicular or transaxillary approach. During the
supraclavicular exposure, the phrenic nerve is identified in front of the scalenus anticus, and
scalenectomy at its attachment to the first rib is performed, preferably using Mayo scissors,
and the scalenus anticus origin is divided from the C6 transverse process. The brachial plexus
will become apparent after division of the scalenus anticus. It should be brought forward with
gentle retraction to expose the scalenus medius. Before dividing the scalenus medius, the long
thoracic nerve must be identified. This nerve exists at the anterolateral border of the scalenus
medius and courses inferolaterally. The posterior neck of the first rib is exposed with a periosteal elevator. The lateral musculofascial attachments to the first rib are then released anteriorly
from its posterior neck to the scalene tubercle. The pleural apex is bluntly dissected from the
inferior surface of the first rib. With the brachial plexus roots well protected from the neck of the
first rib, which is divided sharply with a bone cutter, the anterior portion of the first rib is then
exposed underneath the clavicle and similarly divided just medial to the level of the scalene
tubercle, with protection of the subclavian vein, artery, and nerve roots. When the cervical rib
is present, it should be resected after the middle scalenectomy is completed. It is exposed at its
posterior origin and the neck of the rib is divided, protecting the origin of the nerve root
(C8 and T1). The proximal end of the first rib is detached from its attachment of the first rib and
removed as a specimen. When the cervical rib is present, it is resected after the middle scalenectomy is completed. It is exposed at its posterior origin and the neck of the rib is divided,
protecting C8 and T1 from injury as the proximal end of the cervical attachment of the rib is
detached from its first rib.
Correct Answer C Long thoracic nerve
Reference
Karam, J., & Thompson, R. (2017). Neurogenic thoracic outlet syndrome. In S. S. Hans, A. D. Shepard,
H. R. Weaver, P. G. Bove, & G. W. Long (Eds.), Endovascular and open vascular reconstructions: a
practical approach (pp. 377–382). Boca Raton, FL: CRC Press.
3. RATIONALE
Effort-induced axillary-subclavian vein thrombosis, also known as Paget–Schroetter syndrome,
is an underrecognized cause of upper extremity deep venous thrombosis. This represents
venous manifestation of thoracic outlet syndrome, where the underlying cause is the compression of and repetitive injury to the subclavian vein between the first rib and clavicle. In patients
with an acute-to-subacute presentation, restoring the patency of the subclavian vein is of paramount importance and is most rapidly achieved by pharmocomechanical thrombolysis. After
thrombolysis, patients are maintained on systemic anticoagulation to prevent early recurrent
thrombosis. Surgical management of venous thoracic outlet syndrome can be performed by
the transaxillary approach and infraclavicular approach. A paraclavicular approach for venous
thoracic outlet syndrome allows for complete decompression of the thoracic outlet and possible reconstruction of the subclavian vein during the same operation. Following the standard
supraclavicular decompression, complete medial resection of the first rib and external venolysis
of the subclavian vein after thoracic outlet decompression are performed. The decision to perform patch angioplasty or bypass grafting is made using the venogram. Visualization of the vein
and digital palpation, cryopreserved femoral vein grafts, patch angioplasty, or bypass should
be considered, and the patient is anticoagulated with intravenous heparin and continuous
92 Section 7: Thoracic Outlet Syndrome
infusion of Dextran. A patient presenting with swelling 6 months after thoracic outlet decompression with long segment chronic occlusion of the subclavian/axillary vein should be managed with compression therapy. In some cases where a long bypass graft is constructed, a
temporary (12 weeks) conjunctive radiocephalic fistula may also be constructed for those at risk
to improve venous flow.
Correct Answer C Compression sleeve
Reference
Karam, J., & Thompson, R. (2017). Vascular thoracic outlet syndrome. In S. S. Hans, A. D. Shepard, H. R.
Weaver, P. G. Bove, & G. W. Long (Eds.), Endovascular and open vascular reconstructions: a practi-
cal approach (pp. 371–376). Boca Raton, FL: CRC Press.
4. RATIONALE
Patients with arterial thoracic outlet syndrome have fixed arterial lesions such as stenosis,
occlusion, or aneurysmal dilatation of the subclavian artery as it passes over the first rib, which
is the least frequent form of thoracic outlet syndrome, representing 1%–3% of all thoracic outlet
syndrome cases. This is usually due to compression by an osseous abnormality such as a cervical rib (70%), whereas anomalous first ribs and a tight ligamentous band or other bony abnormalities account for the rest of the structural anomalies causing compression of the subclavian
artery. Clinical manifestations include arterial ischemia caused by embolic or thrombotic
occlusions. Patients presenting with acute arm ischemia are treated initially with thrombolysis
or surgical thrombectomy depending on the level of the occlusion and type of presentation.
After distal circulation is restored, patients are prepared for thoracic outlet decompression
within a few days of the initial procedure. The operative procedure is similar to the one used for
neurogenic thoracic outlet syndrome. The decision to repair the subclavian artery with a bypass
graft versus patch angioplasty depends on the extent of the aneurysm or embolizing lesion
along its course. A paraclavicular approach using a cryopreserved femoral vein graft from the
subclavian artery to axillary artery may be necessary.
Correct Answer B 1%–3%
Reference
Karam, J., & Thompson, R. (2017). Vascular thoracic outlet syndrome. In S. S. Hans, A. D. Shepard, H. R.
Weaver, P. G. Bove, & G. W. Long (Eds.), Endovascular and open vascular reconstructions: a practi-
cal approach (pp. 371–376). Boca Raton, FL: CRC Press.
5. RATIONALE
Residual neurological symptoms of numbness and tingling in the hand or fingers are common
early after thoracic outlet decompression arising as a result of previous neurological damage,
intraoperative mobilization of the brachial plexus, and postoperative inflammation and perineural wound healing. Spontaneous resolution of such symptoms usually occurs within several
days to weeks but may persist for several months. Some patients with long-standing neurogenic
thoracic outlet syndrome can often display residual symptoms that may not be completely
eliminated by thoracic outlet decompression. In some patients, peri-incisional skin hypersensitivity after the operation may be quite significant, and when combined with hypersensitivity symptoms extending to the upper limb, consideration should be given to the diagnosis of
Section 7: Thoracic Outlet Syndrome 93
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
complex regional pain syndrome (CRPS). Early recognition of CRPS and specific forms of physical therapy, stellate ganglion blocks, may be useful in symptomatic relief of recurrent symptoms
that are often accompanied by an increase in arm activity and from secondary injury.
Correct Answer C 5%
Reference
Rochlin, D. H., Likes, K. C., Gilson, M. M., et al. (2012). Management of unresolved, recurrent, and/or
contralateral neurogenic symptoms in patients following first rib resection and scalenectomy.
J Vasc Surg, 56(4), 1061–1067; discussion 1068. PMID: 22770848
6. RATIONALE
Nerve injury after decompression of thoracic outlet syndrome often manifests as persistent
nerve dysfunction over time. In most of these situations, nerve injury rarely presents as an
obvious injury identified in the operating room or as a significant deficit immediately after the
operation, but more often is evident as persistent nerve dysfunction over time. In patients where
the affected nerve was observed to be anatomically intact at the time of surgery, full functional
recovery can be anticipated after several weeks to months. Minimizing handling of the nerves,
dissecting perineural tissue under direct vision, and minimal nerve retraction of individual
nerve roots should be taken under consideration. The presence of a cervical rib or ligamentous
band may displace the brachial plexus much more forward, and scalene muscle abnormalities
(a scalene minimus muscle) and fibroelastic band may obscure the lower nerve root. Division
of the anterior scalene muscle from the first rib should be done with a finger placed between
the muscle and the underlying brachial plexus and subclavian artery using scissors rather than
electrocautery. Prior to resection of the scalene medius, the brachial plexus should also be
mobilized in such a way that all five nerve roots are visible and gently retracted medially. Full
visualization of the T1 nerve root should also be obtained, where it passes underneath the first
rib to join the C8 nerve root before dividing at the posterior neck of the first rib. Although the C8
nerve root typically joins within 1–2 cm of the first rib, one anomaly that can increase the risk of
injury is a long T1 nerve root, which may run for 3–4 cm underneath the first rib before passing
across the bone to join the C8 nerve root. In this setting an unrecognized long T1 nerve root may
be injured by the instrument used to divide the rib, reinforcing the need to divide the rib under
direct vision and protect the C8–T1 junction and lower trunk of the brachial plexus before dividing the posterior portion of the first rib.
Correct Answer D Anatomic variations, intraoperative bleeding, and preoperative repetitive
hyperextension neck trauma
Reference
Duwayri, Y. M., & Thompson, R. W. (2014). Supraclavicular approach for surgical management of tho-
racic outlet syndrome. In Elliott L. Chaikof and Richard P. Cambria (Eds.), Atlas of vascular sur-
gery and endovascular therapy (pp. 172–192). Philadelphia, PA: Elsevier Saunders.
7. RATIONALE
Brachial plexus compression by the pectoralis minor muscle has become increasingly appreciated as a factor contributing to neurogenic thoracic outlet syndrome. It has been reported
that up to 10% of patients with neurogenic thoracic outlet syndrome exhibit physical findings
94 Section 7: Thoracic Outlet Syndrome
that are isolated to the subcoracoid space, and 85%–90% have findings that co-localize to both
the scalene triangle and the subcoracoid space. Even in patients with findings predominately
localized to the scalene triangle, residual nerve compression at the site of the pectoralis minor
muscle may be a source of persistent or recurrent neurogenic thoracic outlet syndrome. Simple
division of the pectoralis minor tendon below the coracoid process may provide substantial
relief of brachial plexus compression with minimal addition to the operative procedure.
Correct Answer A Up to 10%
Reference
Vemuri, C., Wittenberg, A. M., Caputo, F. J., et al. (2013). Early effectiveness of isolated pectoralis minor
tenotomy in selected patients with neurogenic thoracic outlet syndrome. J Vasc Surg, 57(5),
1345–1352. PMID: 23375605
8. RATIONALE
The primary advantage of the supraclavicular approach is excellent exposure of all the relevant
anatomy, allowing more complete decompression with first rib resection, complete scalenectomy, and thorough brachial plexus neurolysis. This approach is thereby applicable to all three
forms of thoracic outlet syndrome with a transaxillary approach; first rib resection as well as
cervical rib resection can be carried out with a hidden incision. Following decompression, an
upright chest X-ray is performed in the recovery room and a few days after decompression to
detect any air or pleural fluid collection. Postoperative analgesia is initially provided by patientcontrolled intravenous opiates. Continuous-infusion local anesthesia may also be used for several days, administered through small-caliber perfusion catheters placed at the time of surgery.
A closed-suction drain placed at the time of the operation is removed when daily output is less
than 50 cc, usually 5–7 days after supraclavicular decompression. Full activity is permitted after
2–3 months.
Correct Answer B Incision in the hidden axillary space and sufficient exposure for the resection of both the first rib and cervical rib
Reference
Rinehardt, E. K., Scarborough, J. E., & Bennett, K. M. (2017). Current practice of thoracic outlet decom-
pression surgery in the United States. J Vasc Surg, 66(3), 858–865. PMID: 28579292
SECTION 8: AORTOILIAC DISEASE
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
MCQs 1–105
Q1. During open repair of an abdominal aor-
tic aneurysm (AAA) without involvement
of the common and external iliac arteries,
distal anastomosis to the femoral artery
should be avoided in order to prevent:
A. Increased incidence of surgical site infec-
tion and late development of anastomotic aneurysm
B. Increased incidence of retrograde
ejaculation
C. Increased incidence of graft limb
occlusion
D. Increased incidence of sigmoid colon
ischemia
Q2. A 70-year-old man with a 7-cm juxtarenal
abdominal aortic aneurysm with moderately severe COPD has a left retroaortic
renal vein on CTA imaging. The preferred
method of repair is:
A. Transperitoneal midline approach
B. Transperitoneal transverse incision
approach
C. Left retroperitoneal approach with the
left kidney remaining in its anatomical
position
D. Left retroperitoneal approach with the
plane of dissection behind the left kidney
Q3. The incidence of incisional hernia follow-
ing 6 years of open midline repair of an
abdominal aortic aneurysm is:
A. <5%
B. <10%
C. 10%–15%
D. 16%–20%
Q4. Significant colon ischemia following open
repair of an unruptured AAA occurs in:
A. <1% of patients
B. 1%–2% of patients
C. 2%–4% of patients
D. Colon ischemia occurs in patients with a
history of left colectomy with an incidence of 5%
Q5. Graft infection following repair of an
uncomplicated AAA occurs in:
A. <1% of patients
B. 1%–2% of patients
C. >2% of patients
D. Graft infection occurs only following
repair of a ruptured AAA
Q6. During repair of a large juxtarenal
AAA with a 3.4-cm right common iliac
artery aneurysm via the transperitoneal
approach, proximal clamping of the aorta
is facilitated by:
A. Ligation of the left renal vein medial to
the gonadal and adrenal vein
B. Division of the left renal vein and its
reanastomosis after completion of proximal anastomosis
C. Supraceliac control
D. Balloon occlusion of the suprarenal aorta
Q7. During open repair of a suprarenal aortic
aneurysm, the best exposure can be
achieved using a:
A. Midline celiotomy with inframesocolic
approach
B. Thoracoabdominal incision through the
7th intercostal space
C. Midline celiotomy with medial visceral
rotation
D. Left flank retroperitoneal approach
through the left 10th intercostal space
DOI: 10.1201/9781003389897-8
96 Section 8: Aortoiliac Disease
Q8. In a patient with a proximal AAA extend-
ing to the level of the SMA, proximal
control of the aorta is best obtained by:
A. Clamp placement at the supraceliac level
B. Clamp placement above the SMA but
below the celiac
C. Intraluminal control by advancing and inflat-
ing an aortic balloon occlusion catheter
D. Supraceliac balloon occlusion using left
brachial access
Q9. During open repair of a para-visceral
AAA, renal ischemia time >30 minutes is
anticipated. The base management strategy to reduce the risk of AKI consists of:
A. Mannitol infusion prior to aortic
cross-clamp
B. Infusion of sodium bicarbonate during
the period of proximal aortic clamping
C. Perfusion of the renal arteries with a
solution of cold Ringer’s lactate, heparin,
mannitol, and methylprednisolone during aortic occlusion
D. Maintaining the patient’s temperature at
32–34°C
Q10. During open repair of a para-visceral
AAA, the left renal artery can be
reconstructed:
A. Leaving it on an anterior tongue of the
aorta including the right renal, SMA, and
celiac artery
B. Bypassing with a sidearm graft previously
sewn on the aortic prosthesis
C. Reimplanting it directly onto the aortic
prosthesis
D. All of the above are acceptable tech-
niques depending on the local anatomy
Q11. Repair of a thoracoabdominal aortic
aneurysm repair (TAAA) should be considered when the aneurysm reaches the
maximum transverse/AP diameter of:
A. 5.0 cm
B. 5.5 cm
C. 6.0 cm
D. 7.0 cm
Q12. The best strategy for reducing the risk of
spinal cord ischemia during repair of a
TAAA is:
A. Epidural cooling
B. Distal aortic perfusion using a temporary
axillary femoral shunt
C. Distal aortic perfusion with intraopera-
tive motor evoked potential monitoring
D. Quick clamp and sew technique without
distal aortic perfusion
Q13. During repair of a TAAA, the left atrial
femoral bypass is initiated. Mean distal
perfusion pressures should be maintained
at:
A. 35–39 mmHg
B. 40–50 mmHg
C. 51–59 mmHg
D. 60–70 mmHg
Q14. Operative mortality for open TAAA repair
is 8%–16%. Open repair of such an aneurysm is contraindicated in patients with
CKD with a GFR less than:
A. 30 cc
B. 40 cc
C. 50 cc
D. 60 cc
Q15. The most common predictors of spinal
cord ischemia after TAAA repair are:
A. Repair of type IV thoracoabdominal aor-
tic aneurysm
B. Advanced age
C. Type I–III thoracoabdominal aortic
aneurysm
D. Type I–III thoracoabdominal aortic aneu-
rysm and urgency of operation
Q16. The incidence of mesenteric ischemia fol-
lowing open repair of a thoracoabdominal
aneurysm is:
A. <1%
B. 1%–2%
C. 2%–3%
D. >3%
Q17. An inflammatory abdominal aortic
aneurysm has a thickened aortic wall with
dense adhesions to the:
A. Jejunum
B. Duodenum and ureter
C. Sigmoid colon
D. Left renal veins
Section 8: Aortoiliac Disease 97
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Q18. During transperitoneal repair of an
inflammatory abdominal aortic aneurysm, the surgical approach is as follows:
A. The third portion of the duodenum
should be separated from the aneurysmal
wall in order to obtain adequate exposure
B. The third and proximal fourth portions of
the duodenum should be left attached to
the aneurysmal wall
C. The ligament of Treitz should not be
mobilized
D. Mandatory ligation and division of left
renal vein and inferior mesenteric vein
Q19. During repair of an inflammatory abdom-
inal aortic aneurysm, there is an injury
to the right common iliac vein, which is
repaired by lateral venorrhaphy. On the
second postoperative day the patient
develops mild discomfort in the right
thigh without any significant swelling
of the right lower extremity. The patient
should now undergo:
A. Venogram of the right lower extremity
B. EMG of the right lower extremity
C. Close observation with serial hematocrit
levels
D. Duplex venous study of the right lower
extremity
Q20. A completion arteriogram following
deployment of a stent graft for repair of
an infrarenal abdominal aortic aneurysm
with a suprarenal fixation device shows a
normal flow to the right kidney but partial
coverage of the left renal artery origin.
Optimal management consists of:
A. Follow-up CTA of the abdomen and pel-
vis in 1 week
B. Bare-metal stent in the left renal artery
using femoral access
C. Self-expanding stent in the left renal
artery via brachial access
D. Bare-metal balloon-expandable stent
using left brachial access in the left renal
artery
Q21. A completion arteriogram following
EVAR reveals 80% coverage of the right
hypogastric artery with known
severe stenosis of the contralateral
hypogastric artery. Optimal management consists of:
A. No treatment necessary
B. Left brachial access with deployment of a
bare-metal stent into the right hypogastric artery
C. Left brachial access with both balloon
angioplasty and stenting of the left hypogastric artery
D. Ipsilateral wire access into the right
hypogastric artery via the right femoral artery with distal limb extension
and internal iliac artery stenting that
extends into the external iliac artery
to permit retrograde perfusion via the
snorkel technique
Q22. A type IA endoleak is seen following
EVAR in an 80-year-old woman with aortic neck angulation of 45 degrees. There
is no resolution following repeat aortic
balloon neck angioplasty. The next best
option is:
A. Snorkeling
B. Consider a large bare-metal stent
(Palmaz) or endostapling
C. Coil embolization of the endoleak site
D. No treatment at this time, but follow-up
CTA scan of the abdomen and pelvis in
4 weeks
Q23. A 67-year-old man presents with right
lower extremity ischemia 6 weeks following EVAR with absent right femoral pulse.
ABI on the right is 0.4 and on the left is
1.0. CTA of the abdomen and pelvis shows
right graft limb occlusion with reconstitution of the proximal external iliac
artery and filling of branches of the right
hypogastric artery. Optimal management
consists of:
A. Crossover femoral-femoral graft
B. Thrombolysis and relining the endograft
and extension of the graft to the right
external iliac artery with coil embolization of the hypogastric artery
C. Anticoagulation
D. Right axillofemoral graft
98 Section 8: Aortoiliac Disease
Q24. One year following EVAR a 75-year-old
man developed a type II endoleak from
a patent inferior mesenteric artery with
sac enlargement by 5 mm. The next best
management option should be:
A. Translumbar sac embolization
B. No intervention at present; follow-up
CTA of the abdomen and pelvis in
6 months
C. Sac embolization using femoral access
with passage of a catheter within the iliac
limb of the endograft and native iliac
artery
D. Coil embolization of the inferior mesen-
teric artery via the superior mesenteric
artery using a microcatheter
Q25. The incidence of ischemic stroke
following chimney parallel grafting
(ch. EVAR) is:
A. <2%
B. 2%–2.9%
C. 3%–3.5%
D. >3.5%
Q26. Branch stent endoleaks following
FEVAR and branched endografts requiring intervention for renal arteries
occur in:
A. <1%
B. 1%–2%
C. 2%–3%
D. >3%
Q27. Results of a U.S. multicenter prospective
study evaluating the Zenith fenestrated
endovascular graft for treatment of a
juxtarenal abdominal aortic aneurysm
showed secondary interventions for renal
artery stenosis/occlusion in:
A. 30% of patients
B. 22% of patients
C. 12% of patients
D. 6% of patients
Q28. Use of intraoperative C-arm cone-beam
computed tomography (CBCT) in fenestrated/branched aortic endografting
showed:
A. Fewer operative minutes
B. Lower fluoroscopy time
C. Lower contrast dose
D. No difference in detection of early
complications
Q29. The prevalence of iliac artery aneurysms
from the most common to least common
is ranked as:
A. Hypogastric artery, common iliac artery,
external iliac artery
B. Common iliac artery, hypogastric artery,
external iliac artery
C. External iliac artery, hypogastric artery,
common iliac artery
D. Common iliac artery, external iliac artery,
hypogastric artery
Q30. Which of the following is an anatomical
requirement for the use of an iliac branch
device?
A. Aortic to iliac bifurcation length <5 cm
B. Hypogastric artery landing zone length
<10 mm
C. Iliac bifurcation inner diameter >16 mm
D. Hypogastric artery landing zone diameter
12 mm
Q31. The incidence of abdominal compart-
ment syndrome following open repair of a
ruptured AAA is:
A. 10%
B. 15%
C. 20%
D. >20%
Q32. Spinal cord ischemia (SCI) following
repair of a ruptured AAA occurs in:
A. <1% of patients
B. 1%–2% of patients
C. >2% of patients
D. Spinal cord ischemia occurs only follow-
ing repair of a thoracic aortic aneurysm
Q33. A 72-year-old woman with profound
hypotension secondary to a ruptured
juxtarenal AAA should be taken to the
hybrid OR, and proximal control should
be obtained by:
A. Thoracic aortic balloon occlusion using
femoral artery access in the OR
B. Thoracic aortic balloon occlusion using
left brachial artery access in the OR
Section 8: Aortoiliac Disease 99
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
C. Laparotomy and supraceliac control
D. Retrograde passage of a large bal-
loon Foley catheter advanced from
an opening in the aortic neck during
laparotomy
Q34. During open repair of a ruptured AAA,
there is injury to the left renal vein lateral
to the gonadal vein and adrenal vein with
a 30% loss of circumference. Mean blood
pressure is 70 mmHg. Optimal management consists of:
A. Lateral venorrhaphy
B. Ligation of the left renal vein
C. Splenic vein to left renal vein bypass
D. Vascular clamps on either side of the left
renal vein and repair after proximal aortic
anastomosis is completed
Q35. The incidence of pancreatitis and
duodenal obstruction is highest following:
A. Open repair of unruptured AAA
B. Aortobifemoral grafting
C. Open repair of ruptured AAA
D. Open repair of type IV thoracoabdominal
aneurysm
Q36. Following completion of distal anasto-
mosis during open repair for ruptured
AAA, the patient has diffuse oozing from
exposed surfaces. Lab data: hemoglobin
9.2 gm, hematocrit 26, platelets 84,000,
INR 1.8, fibrin split products normal.
The most common cause of this abnormality is:
A. Disseminated intravascular coagulopathy
B. Secondary fibrinolysis due to visceral
ischemia from supraceliac clamping
C. Dilutional coagulopathy
D. Primary fibrinolysis
Q37. A 64-year-old man presents to the emer-
gency room with a leaking AAA. CT scan
shows a horseshoe kidney with small retroperitoneal hematoma. The most important criterion in deciding the method of
repair (open or endovascular) is:
A. Experience of the surgeon
B. Open repair is mandatory in all patients
with a horseshoe kidney
C. Endovascular repair should be
preferred
D. Should be decided by the anatomy of
the aneurysm and arterial supply to the
horseshoe kidney
Q38. A 78-year-old man presents to the
emergency room with a leaking AAA
with antecedent endovascular
aneurysm repair. The optional management is:
A. Mandatory open repair
B. Repair of ruptured AAA in a patient
with a prior endograft is uniformly
fatal so only palliative care should be
recommended
C. Mandatory endovascular repair
D. Choice of endovascular versus
open repair depends on the findings
of the CTA of the abdomen and
pelvis and clinical condition of the
patient
Q39. Endovascular repair of a ruptured AAA in
a high-risk patient with prior EVAR with
a large type IA endoleak required intentional coverage of one renal artery. The
following best reflects the outcome in this
situation:
A. Single renal artery coverage does
not increase the odds of permanent
dialysis/30-day mortality
B. Single renal artery coverage increases the
risk of dialysis but does not increase the
30-day mortality
C. Single renal artery coverage increases
the odds of permanent dialysis/30-day
mortality primarily due to the need for
permanent dialysis
D. Single renal artery coverage results in
prohibitive mortality and should not be
performed
Q40. The incidence of late open conversion
following EVAR is:
A. <1%
B. 1%–5%
C. 0%–10%
D. 11%–12%
Соседние файлы в папке Библиотека им академика М.И. Перельмана