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Most common congenital hypercoagulaboe disorder
Leiden factor (resistance to protein C)
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Most common aquired hypercoagulability disorder
Smoking
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Macrophages that have absorbed fat and lipids in the blood vessel wall
Foam cells
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Exposure of collagen in vessel wall and eventual throbus formation
Intimal disruption
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Atherosclerosis: layer that it effects
Intima
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Hypertension: layer that it effects
Media
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3rd most common cause of death in US
stroke
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amount of blood supply provided to brain by carotids
85%
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flow pattern of a normal internal carotid artery
continuous forward flow
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normal flow pattern of the external carotid artery
triphasic flow
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1st branch of external carotid artery
superior thyroid
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vessels that provide communication between internal carotid and external carotid (2)
ophthalmic artery, internal maxillary artery
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most commonly diseased intracranial artery
middle cerebral artery
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most common source of cerebral ischemic events
arterial embolization from ICA
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symptoms associated with anterior cerebral artery events
mental status changes, release, slowing
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symptoms associated with middle cerebral artery events
contralateral motor and speech, face droop
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occlusion of ophthalmic branch of ICA causing transient visual effects
amaurosis fugax
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candidates for CEA
>= 70% stenosis and symptoms
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stump pressures requiring shunt during CEA
>50
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most commonly injured cranial nerve during CEA
vagus
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complications of CEA
stroke, pseudoaneurysm, hypertension, MI
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signs of vertebrobasilar insufficiency (7)
diplopia, dysarthria, vertigo, tinnitus, drop attack, incoordination, binocular vision loss
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tumor presenting as painless neck mass near bifurcation of carotid
carotid body tumor
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symptoms of ascending aortic aneurysm
aortic insufficiency, back pain, voice changes, dyspnea, dysphagia
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indications for repair of ascending aortic aneurysm (4)
>=7cm, >=6cm with Marfan�s, diameter 2X normal, rapid increase in size
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aneurysm classification for those with any ascending aortic involvement
Class A
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Aneurysm classification for those with descending involvement only
Class B
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DeBakey classification for aneurysms with ascending an descending involvement
Type I
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DeBakey classification for aneurysms with ascending involvement only
Type II
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DeBakey classification for aneurysms with descending involvement only
Type III
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Layer of blood vessel where dissection occurs
Media
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Ascending aortic dissections that need operative repair
ALL of them
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Descending aortic dissections that need operative repair
Visceral, renal or leg ischemia, persistent pain, large size
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Artery perfusing spinal cord, whose injury causes paraplegia if occluded during repair
Artery of Adamkiewicz
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Symptoms of AAA
Rupture, distal embolixation, compression of adjacent organs
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Rupture risk of AAA 5cm
15-20% 5-year
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rupture risk of AAA >8cm
100% 5-year
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indications for AAA repair (3)
symptomatic, >5cm, growth >0.5cm/yr
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situations when IMA should be reimplanted during AAA repair
backpressure <40mmHg, previous colon surgery, SMA stenosis, inadequate flow to colon
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bloody diarrhea after AAA: dx?
Ischemic colitis
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Organisms common in mycotic aneurysms (2)
Salmonella, staph
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Treatment of mycotic aneurysm
Extraanatomic bypass, resection of infected portion of aorta
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Organisms common in aortic graft infections (2)
Staph, E.coli
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Treatment of aortic graft infection
Resect graft, bypass through noncontaminated field
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Herald bleed with hematemesis, then blood per rectum ~6mos after AAA
Aortoenteric fistula
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Treatment of aortoenteric fistula
Axillary bifem, graft resection
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Endoleak that is proximal, distal, or through the stent
Type I endoleak
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Endoleak that is persistent blood flow through lumbars or IMA
Type II endoleak
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Nerve and vessel in anterior compartment of leg
Deep peroneal nerve, anterior tibial artery
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Nerve in lateral compartment of the leg
Superficial peroneal nerve
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Nerve and 2 vessels in the deep posterior compartment of the leg
Tibial nerve, posterior tibial and peroneal arteries
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Nerve in superficial posterior compartment of the leg
Sural nerve
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Treatment of homocysteinuria
Folate, B6, B12
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Yearly risk of gangrene and amputation with claudication
2%/year and 1%/year
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symptoms of aortoiliac occlusion
buttock pain
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symptoms of external iliac occlusion
midthigh claudication
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symptoms of common femoral or proximal superficial femoral artery occlusion
calf claudication
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symptoms of distal SFA or popliteal disease
foot claudication
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syndrome with a lesion at or above aortic bifurcation, causing lack of femoral pulse, buttock/thigh claudication, impotence
Leriche syndroma
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Most common atherosclerotic occlusion in lower extremities
Hunter�s canal (exit of SFA)
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ABI where claudication starts
<0.9
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ABI where rest pain starts
<0.6
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ABI where ulcers start (usually on toes)
<0.5
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ABI where gangrene starts
<0.3
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studies to find significant occlusion and at what level
PVRs (peripheral vascular resistance studies
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Gold standard for vascular imaging to detect occlusion
Angiogram
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Surgical indications for PVD (4)
Rest pain, ulceration or gangrene, lifestyle limitation, atheromatous embolixation
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Graft material good for aorta and large vessels
Dacron
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Typeical repair for aortoiliac disease
Aortobifemoral repair
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5-year patency of femoropopliteal grafts
75%
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5-year patency of femoral-distal grafts
50%
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complications of reperfusion of ischemic tissue (4)
lactic acidosis, hyperkalemia, myoglobinuria, compartment syndrome
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tx for patients with heel ulceration to bone
amputation
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tx for patients with dry gangrene
allow to autoamputate
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tx for wet gangrene
amputation to remove infected necrotic tissue + antibiotics (surgical emergency)
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good lesions for PCTA
common iliac lesions, short segments
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tx for pseudoaneurysm after arteriography
thrombin injection (u/s guided)
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most common compartment of leg to get compartment syndrome
anterior
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pressures requiring fasciotomies
>20-30
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mild intermittent claudication in med in their 40�s; primary symptom is loss of pulses with plantarflexion
popliteal entrapment syndrome
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treatment for popliteal entrapment syndrome
resection of medial head of gastroc
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intermittent claudication with changes in symptoms with knee flexion and extension
adventitial cystic disease
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tx of adventitial cystic disease
vein graft if occluded, resection of cyst
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3-year mortality after BKA or AKA
50%
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% of patients who walk again after BKA
70
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% of people who walk again after AKA
30%
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most common cause of acute arterial emboli
atrial fibrillation
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most common site of peripheral obstruction from emboli
common femoral artery
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flaking of atherosclerotic emboli off abdominal aorta or branches; good distal pulses
blue toe syndrome
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treatment of acute arterial thrombosis
heparin, OR for thrombectomy (if limb threatened), angio for thrombolytics (if limb not threatened)
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treatment of thrombosed PTFE graft
thrombolytics, anticoagulation
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source of most renal emboli
heart
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most common location for renal atherosclerosis
Left proximal 1/3, more in men
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Most common location for renal fibromuscular dysplasia
Right distal 1/3, more in women
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Diagnostic study for renal artery stenosis
Renal angiogram
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Tx of renal artery stenosis
PTA with stent
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Indications for nephrectomy with renal HTN
Atrophic kidney <6cm with persistently elevated rennin level
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Most common site of upper extremity stenosis
Subclavian
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Proximal subclavian artery stenosis resulting in reversal of flow through ipsilateral vertebral artery into subclavian
Subclavian steal syndrome
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Treatment of subclavian steal syndrome
Carotid to subclavian bypass or PTA
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Normal position of subclavian vein in relation to ribs, scalene and clavicle
Vein passes over 1st rib anterior to anterior scalene, then behind clavicle
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Normal position of subclavian artery and brachial plexus in relation to ribs, scalene and clavicle
Artery passes over 1st rib posterior to anterior scalene and anterior to middle scalene
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Test looking at radial pulse with head turned to the ipsilateral side
Adson�s test
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Location of ulnar nerve on brachial plexus (superior, middle, or inferior)
Inferior portion
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Location of radial nerve on brachial plexus (superior, middle or inferior)
Superior portion
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Treatment of thoracic outlet syndrome
Cervical rib resection, division of anterior scalenes and middle scalenes. Possible 1st rib resection
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Effort induced thrombosis of subclavian vein
Paget von Schrotter disease
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CT findings that suggest intestinal ischemia
Bowel wall thickening, intramural gas, portal venous air, vascular occlusion
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Most common cause of visceral ischemia
Acute embolic occlusion (50%)
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Causes of visceral ischemia (4)
Embolus, thrombotic occlusion, low flow state, venous thrombosis
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Most common source of SMA embolus
Heart
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Treatment of SMA embolus
Resuscitation, antibiotics, embolectomy, resection, heparin
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Treatment of SMA thrombus
Thrombectomy, SMA bypass, resection, heparin
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Treatment of mesenteric vein thrombosis
Heparin, thrombolytics, thrombectomy if diagnosed early
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Nonocclusive mesenteric ischemia: definition
low cardiac output state to visceral vessels caused by spasm, low-flow states, or hypovolemia
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most vulnerable areas for nonocclusive mesenteric ischemia (2)
Griffiths and Sudak�s points
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Celiac compression causing chronic abdominal pain, weight loss, diarrhea
Median arcuate ligament syndrome
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Visceral angina 30 min after meals, weight loss due to food fear
Chronic mesenteric ischemia
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Most common complication of aneurysms above inguinal ligament
Rupture
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Most common complication of aneurysms below inguinal ligament
Thrombus/emboli
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Most common visceral aneurysm in women
Splenic
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Indications for splenic artery aneurysm repair
Symptomatic, pregnancy, women of childbearing age
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Treatment of visceral, iliac and femoral aneurysm
Exclusion and bypass graft
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Indications for surgery for iliac aneurysm
Symptomatic, >3cm, mycotic
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Indications for surgery for femoral aneurysm
Symptomatic, >2.5cm, mycotic
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Most common peripheral aneurysm
Popliteal
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% of people with popliteal aneurysm who have another aneurysm
50%
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surgical indications for popliteal aneurysm
symptomatic, >2cm, mycotic
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collection of blood in continuity with arterial system but unenclosed by all 3 layers of arterial wall
femoral pseudoaneurysm
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disease with string of beads appearance on angiogram
fibromuscular dysplasia
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gangrene of fingers>toes, severe rest pain with bilateral ulceration
Buerger�s disease
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Type I collagen defect causing retinal detachment, aortic root dilatiation
Marfan�s syndrome
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Collagen defect resulting in easy bruising, hypermobile joints, arterial rupture
Ehlers-Danlos syndrome
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Large artery arteritis causing fever, arthralgia, visual changes, myalgia, anorexia (common in women >55)
Temporal arteritis
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Large artery arteritis causing fever, arthralgia, myalgia, and anorexia (common in women <35)
Takayasu�s arteritis
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Treatment of large vessel arteritis
Steroids, bypass
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Medium vessel arteritis (2)
Polyarteritis nodosa, kawasaki�s disease
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Small vessel arteritis, often secondary to drug/tumor antigens
Hypersensitivity angitis
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Vasculitis of young women with subsequent vasoconstriction and cyanotic extremities
Raynaud�s disease
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Most common failure of AV grafts for dialysis
Venous obstruction secondary to intimal hyperplasia
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Indications for surgical treatment of varicose veins
Symptomatic, recurrent ulcers, severe varicosities
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Disease secondary to venous incompetence
Venous ulcers
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Treatment of venous ulcers
Unna boot, ligate perforators, vein stripping
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Trendelenburg test
Test of venous insufficiency: elevate leg, occlude greater saphenous, then lower leg to see how rapid the refilling of the vein is
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Disease with achy, swollen legs and night cramps, as well as brawny edema
Venous insufficiency
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Nonbacterial inflammation of superficial veins
Superficial thrombophlebitis
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Bacterial infection of superficial veins
Suppurative thrombophletibis
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Self-limiting thrombophlebitis of the breast
Mondor�s disease
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Methods by which SCD�s prevent clots (3)
Decreased venous stasis, increased ATIII and tPA, increased fibrinolysis
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Leg more commonly affected by DVT
Left (longer iliac vein compressed by iliac artery)
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Virchows triad
Venous stasis, hypercoaguability, venous wall injury
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Tenderness, pallor and edema of lower extremity
Phlegmasia alba dolens
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Tenderness, cyanosis and massive edema of lower extremity
Phlegmasia cerulea dolens
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Source of PE when a DVT filter is in place (3)
Ovarian veins, IVC superior to filter, upper extremities
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Treatment of 1st DVT
Coumadin 6 months
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Treatment of 2nd DVT
Coumadin 12 months
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Treatment of 3rd DVT or PE
Lifetime Coumadin
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ABG changes of PE
Dec pO2, dec pCO2, respiratory alkalosis
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Tissue types with no lymphatics (6)
Bone, muscle, tendon, cartilage, brain, cornea
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Lymphangiosarcoma associated with breast axillary dissection
Stewart-Treves syndrome
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Dilation of preexisting lymphatic channels
Lymphangiectasia
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