Atherosclerosis pathology: (intima disease)

  • Stage I: Foam cells (macrophages that have phagocyted lipids)
  • Stage II: Smooth muscle cell proliferation due to mac's release of growth factors.
  • Stage III: Intimal disruption (exposes collagen) -> thrombus formation

First branch o external carotid artery:

  • Superior thyroid artery

ACAS: Asymptomatic Carotid Atherosclerosis Study

  • (Patients with >60% stenosis)

  • CEA reduces 5 year stroke rate from 11 to 5.1%

  • Perioperative risk of morbidity and mortality was only 3%

  • Therefore:
    • Pt’s with asymptomatic carotid stenosis of <60% should be medically managed.
    • Those with lesions >60% should have CEA if their operative mortality is <3%
    • (Age <79 and stable cardiac function.)

NASCET: North American Symptomatic Carotid Endarterectomy Trial

  • (Patients with >70% stenosis)
  • CEA reduces 2 year stroke rate from 26 to 9%
  • Therefore:
    • All pts with symptomatic stenosis of >70% should undergo CEA
    • Those with stenosis of <50 % should be medically managed
    • Pt’s with lesion 50-70% should have CEA if they are at high risk for CVA
    • (Age >75, have severs stenosis, male, hemispheric Sx’s, CVA < 3 moths from study, higher grade stenosis, or Intra cranial stenosis is also present)

If B/L stenosis:

  • Repair the tightest side first
  • If equal stenosis è repair the dominant side first

#1 CN injury with CEA: Vagus nerve (clamp application)

  • Hoarseness

Post-CEA pseudoaneurysms:

  • US/MRI are preferred over angiogram to avoid embolic complications
  • In case of emergency (post op paralysis) è OR
  • è Repair is usually required

Thoraccic Aortic Transection:

  • Get mediastinal widening from bridging veins and arteries, not leaking from aorta itself
  • Usually tears at the ligamentum arteriosum just distal to the left subclavian.

Ascending aortic aneurisms:

  • Also referred to as familial aortic dissection
  • Usually caused by connective tissue disorders (cystic medial necrosis, Marfan’s syndrome)

AAA rupture risk:

  • < 5cm = 20% in 5 years
  • 5-7 cm = 33%
  • >7cm = 95%
  • Risk increases w/ HTN & COPD

Bloody diarrhea first few days s/p AAA repair:

  • Demands sigmoidoscopy to evaluate for ischemic colon (due to loss of IMA).
  • Take to OR if necrosis

Reimplant IMA if: Backpressure <40 mmHg

Mycotic aneurysms: Sallmonella#1, Staph#2

Aortic graft infections: Staph #1, E.Coli #2


  • Type I: Proximal or distal attachment sites
  • Type II: Persistent blood flow through lumbars or IMA
  • Type III: Caused by fabric tears or graft interface of modular device
  • Type IV: Transient extravasation (porosity of the graft or needle holes)


  • Initial Tx:
    • Smoking cessation
    • Exercise
    • Trental
    • Not surgery

Popliteal aneurysm:

  • #1 peripheral aneurysm
  • 50% bilateral
  • 1/3rd have AAA
  • Surgery indications: symptomatic, > 2cm, mycotic
  • Risk of emboli and thrombosis, so operate (exclude and bypass)

Visceral aneurysms:

  • Splenic #1 (60%)
  • Tx if:> 2 cm, child bearing age or planning pregnancy, or symptomatic

Fibromuscular dysplasia:

  • Young women with HTN (if renal a. involved)
  • Most commonly involved vessel:
  • Right renal artery
  • Followed by carotid and iliac
  • Most common variant:
  • Medial Fibrodysplasia
  • Tx: Percutaneous Trans-luminal Angioplasty (first choice) or bypass

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