Книга_3757_Библиотеки_им_академика_М_И_Перельмана

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388

acial

Fig. 37.5 Intraoperative photo following tumor resection with preservation of arterial structures

Fig. 37.6 Image illustrating ligation external carotid artery in case of complex carotid body tumor

M. R. Weaver

ost belly

digastric

Carotid body tumor

Common f vein

divided to assist with mobilization and resection (Fig.37.6). This maneuver also serves to devascularize the tumor.

More advanced tumors with greater involvement with the artery will require arte-

rial resection of the carotid bulb, or internal carotid artery will require some type of arterial repair such as lateral arteriorrhaphy, patch angioplasty, or bypass (Fig.37.7). In cases where the tumor completely encases the artery, the tumor and artery are resected en bloc, followed by arterial reconstruction usually with saphenous vein. When carotid artery clamping and/or reconstruction are required, monitored anticoagulation is instituted, along with selective shunting depending on the

X nerve

Ansa cervicalis

37 Carotid Body Tumor Resection

Fig. 37.7 Image illustrating external carotid artery excision and internal carotid artery repair in case of complex carotid body tumor excision

XII nerve

389

intraoperative electroencephalography ndings. Attempt is made to remove all tumors as incomplete excision made lead to local recurrence.

Having completed resection of the tumor and any arterial reconstruction, hemo-

stasis is ensured, and any heparin effect if present reversed with protamine. A closed suction drain is placed prior to closure to control residual blood or uid in the resulting dead space and usually removed on post-op day 1 or 2. The platysma is closed over the drain with absorbable suture, and the skin is closed with a running subcuticular suture. Perioperative complications include nerve injury, stroke/transient ischemic attack, and bleeding. Most nerve injuries are secondary to stretch and resolve over time.

Chapter 38

Multiple-Choice Questions

SachinderSinghHans andAlexanderD.Shepard

Chapter 1: Basic Techniques

Question 1 During arterial reconstructions under systemic heparin administration, ACT should

be maintained at:

A. Less than 200 seconds B. 200–250 seconds C. 251–300 seconds D. Greater than 300 seconds

Correct answer: C

Question 2 Interrupted closure of an arteriotomy is most commonly done for closure of the:

A. Femoral artery B. Internal carotid artery C. Brachial artery D. External iliac artery

Correct answer: C

S. S. Hans (*) Vascular and Endovascular Services, Henry Ford Macomb Hospital, ClintonTwp, MI, USA

A. D. Shepard Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA

https://doi.org/10.1007/978-3-031-13897-3_38

391

392

S. S. Hans and A. D. Shepard

Question 3 Eversion endarterectomy is most commonly performed in the:

A. External iliac artery B. Femoral artery C. Common carotid artery D. Internal carotid artery

Correct answer: D

Question 4 During repair of a large femoral anastomotic aneurysm with obliteration of tissue

planes, the control of deep femoral artery is best obtained by:

A. Control with a balloon angioplasty catheter via contralateral femoral

approach B. Ligation of deep femoral artery C. Exposure of distal deep femoral artery in an undissected tissue plane D. Intraluminal control

Correct answer: D

Chapter 2: Abdominal Aortic Aneurysm

Question 1 Just superior to the right renal artery, suprarenal aorta is separated from the

IVC by the:

A. Right crus B. Median arcuate ligament C. Left crus D. Cisterna chyli

Correct answer: A

Question 2 Patient with a retroaortic left renal vein is to undergo open AAA repair using left

ank retroperitoneal approach.

A. Left kidney should be moved anteriorly. B. Left kidney should be left in its bed. C. Retroperitoneal approach is contraindicated. D. Left renal vein can be ligated close to IVC as in transperitoneal approach.

Correct answer: B

Question 3 During repair of AAA without involvement of common and external iliac arteries,

distal anastomosis to femoral artery should be avoided in order to prevent:

38 Multiple-Choice Questions

393

A. Surgical site infection and late development of an anastomotic aneurysm B. Increased incidence of graft seroma C. Increased incidence of graft limb occlusion D. Increased incidence of sigmoid colon ischemia

Correct answer: A

Question 4 During left ank retroperitoneal repair of a large AAA, control of the right common

iliac artery is most safely obtained by:

A. Direct clamping B. Ligation of right common iliac artery and anastomosis to right external iliac

artery using right extraperitoneal approach C. Endoluminal control D. Ligation of right common iliac artery and crossover femoral-femoral graft

Correct answer: C

Chapter 3: Open Repair of Juxtarenal and Infrarenal Abdominal Aortic Aneurysm

Question 1 A patient with 7.5cm infrarenal AAA has a pelvic kidney with its arterial supply

originating from the common iliac arteries on each side. The best management option is:

A. Open repair of AAA with renal autotransplantation B. Axillobifemoral bypass graft during AAA repair to maintain retrograde arte-

rial ow to the pelvic kidney C. Nephrectomy of the pelvic kidney D. Reimplantation of the renal arteries into the prosthetic graft during AAA repair

Correct answer: D

Question 2 A 70-year-old male has 7cm juxtarenal AAA with signicant COPD.CTA of the

abdomen and pelvis shows a normal left renal vein. Preferred mode of repair is:

A. Transperitoneal midline repair B. Transperitoneal transverse incision approach C. Left ank retroperitoneal approach with kidney left in the anatomical position D. Left retroperitoneal approach with plane of dissection behind the left kidney

Correct answer: D

394

S. S. Hans and A. D. Shepard

Question 3 During repair of a large juxtarenal AAA and right common iliac artery aneurysm via

a transperitoneal approach, proximal clamping of the aorta is facilitated by:

A. Ligation of left renal vein medial to the gonadal and adrenal vein B. Ligation of left renal vein lateral to the gonadal vein and adrenal vein C. Supraceliac control D. Balloon occlusion of the supraceliac aorta via left brachial artery approach

Correct answer: A

Chapter 4: Paravisceral Abdominal Aortic Aneurysm Repair Questions

Question 1 During open repair of a suprarenal aortic aneurysm, the best exposure can be

achieved using a:

A. Midline celiotomy with an infra-mesocolic approach B. Thoracoabdominal incision through the eighth intercostal space C. Midline celiotomy with right medial visceral rotation D. Left ank retroperitoneal approach through the tenth intercostal space

Correct answer: D

Question 2 In a patient with an AAA extending 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 inating an aortic balloon occlusion

catheter in the supraceliac aorta D. Balloon catheter occlusion of the supraceliac aorta using femoral artery access

Correct answer: A

Question 3 During open repair of a paravisceral AAA, renal ischemia time >30min is antici-

pated. The best 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 + hepa-

rin, mannitol, and methylprednisolone during aortic occlusion D. Maintaining the patient’s temperature at 32–34°C

Correct answer: C

38 Multiple-Choice Questions

395

Question 4 During open repair of a paravisceral AAA, the left renal artery can be recon-

structed by:

A. Leaving it on an anterior tongue of aorta including the right renal, SM, and

celiac arteries. B. Bypassing it with a side-arm graft previously sewn on to the aortic prosthesis. C. Reimplanting it directly on to the aortic prosthesis. D. All are acceptable techniques depending on the local anatomy.

Correct answer: D

Chapter 5: Open Thoracoabdominal Aortic Aneurysm Repair

Question 1 Repair of a thoracoabdominal aortic aneurysm (TAAA) should be considered when

the aneurysm reaches the maximum transverse/AP diameter:

A. 5cm B. 5.5cm C. 6cm D. 7cm

Correct answer: C

Question 2 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 intraoperative motor evoked potential monitoring D. Quick clamp-and-sew technique without distal aortic perfusion

Correct answer: C

Question 3 During repair of a TAAA, left atrial femoral bypass is initiated. Mean distal perfu-

sion pressure should be maintained as:

A. 35–39mmHg B. 40–50mmHg C. 51–59mmHg D. 60–70mmHg

Correct answer: D

396

S. S. Hans and A. D. Shepard

Question 4 Operative mortality for open TAAA repair 8–16%. Open repair of such aneurysm is

contraindicated in chronic kidney disease patients with a GFR less than:

A. 30cc B. 40cc C. 50cc D. 60cc

Correct answer: A

Chapter 6: Inammatory Abdominal Aortic Aneurysm

Question 1 Inammatory abdominal aortic aneurysm has a thickened aortic wall with dense

adhesions to:

A. Jejunum B. Duodenum and ureter C. Sigmoid colon D. Left renal vein

Correct answer: B

Question 2 During transperitoneal repair of an inammatory AAA:

A. Third portion of duodenum should be left attached to aneurysmal wall. B. Third portion of duodenum carefully separated from duodenal wall. C. Ligament of Treitz should not be mobilized. D. Left renal vein and inferior mesenteric vein always need ligation and division

in order to obtain proximal control.

Correct answer: A

Question 3 Open repair of an inammatory AAA:

A. It should always have placement of ureteral stent prior to open repair. B. Transperitoneal repair is safer than retroperitoneal repair. C. Inammatory AAA has much lower incidence of rupture as compared to

noninammatory aneurysm of similar size. D. Dense inammatory reaction in the retroperitoneal tissues extends from

below the origin of renal arteries to just above the common iliac artery

bifurcation.

Correct answer: D

38 Multiple-Choice Questions

397

Question 4 During repair of an inammatory AAA, there is an injury to right common iliac vein

which is repaired by lateral venorrhaphy. On second post-op day, the patient develops mild discomfort in the right thigh. The patient should undergo:

A. Venogram right lower extremity B. EMG right lower extremity C. Duplex venous study of right lower extremity D. Close observation

Correct answer: C

Chapter 7: Repair of Aortoenteric Fistula

Question 1 The repair of aortoenteric stula is to be performed in a relatively stable patient who

had undergone open repair of AAA previously. The best conduit for aortic reconstruction following removal of remotely placed prosthetic graft is:

A. Rifampin-soaked Dacron graft B. Cryopreserved arterial allograft C. Reconstruction with deep veins (femoral/popliteal) D. Axillobifemoral graft

Correct answer: B

Question 2 During repair of aortoenteric stula, the best method of proximal control of aorta is:

A. Supraceliac aorta via a laparotomy B. Suprarenal aorta via laparotomy C. Balloon occlusion of aorta via femoral artery access D. Balloon occlusion of supraceliac aorta via left brachial artery access

Correct answer: A

Question 3 Following repair of an aortoenteric stula with a direct inline aortic reconstruction,

antibiotics should be administered for:

A. 2 weeks B. 6 weeks C. 3 months D. 6 months–possible lifetime

Correct answer: D

398

S. S. Hans and A. D. Shepard

Chapter 8: Ruptured AAA

Question 1 A 72-year-old female presents to ER with profound hypotension secondary to a

ruptured AAA.The patient should undergo:

A. Thoracic aortic balloon occlusion via femoral approach in ER B. Thoracic aortic balloon occlusion via left brachial approach in OR C. Supraceliac aortic control in OR D. Retrograde passage of a large Foley balloon catheter through the aortic

neck in OR

Correct answer: C

Question 2 During open repair of a ruptured AAA, there is injury to the left renal vein close to

IVC with a 40% loss of circumference. Mean BP is 70mmHg. Optimal management consists of:

A. Lateral repair of left renal vein B. Ligation of left renal vein C. Splenic vein to left renal vein bypass D. Vascular clamps on either side of injured left renal vein and repair of injury

following completion of Proximal anastomosis

Correct answer: A

Question 3 During exposure of the supraceliac artery, which portion of the diaphragm is

dissected?

A. Right crus B. Left crus C. Median arcuate ligament D. Right dome of diaphragm

Correct answer: A

Question 4 During completion of distal anastomosis following open repair of a ruptured AAA,

the patient has diffuse oozing from the exposed surfaces. Hgb = 9.2Gm, Hct= 26, PTT = 54s (normal 25–35), pro time = 16.8s with INR = 1.8, brin split products are normal. The most common cause of this abnormality is:

A. Disseminated intravascular coagulopathy B. Secondary brinolysis from hepatic ischemia with supraceliac clamping C. Dilutional coagulopathy D. Primary brinolysis

Correct answer: C

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