Study Questions: Chapter 17 Chapter 17: Complications of Open and Endovascular Procedures ERIC J. TURNEY, MD; SEAN P. LYDEN, MD Study Questions : Chapter 17 * 1.) Which of the following is the most common cardiac morbidity in open aortic surgery? Myocardial infarction Congestive heart failure Arrhythmia Cardiac arrest Show answerThe correct answer is 3, Arrhythmia. Arrhythmia occurs in 3% of patients undergoing open aortic surgery. The majority of these events are successfully treated with medical therapy and electrolyte correction. MI and CHF each occur 1% of the time, with cardiac arrest being less common. Some recent studies have shown that routine preoperative testing in asymptomatic patients does not create a significant benefit. * 2.) Which of the following is associated with increased stroke in carotid endarterectomy? Intact circle of Willis without contralateral carotid disease Dissection of carotid bifurcation prior to distal control Asymptomatic carotid stenosis Procedure performed at a high-volume center by a high-volume surgeon Show answerThe correct answer is 2, Dissection of carotid bifurcation prior to distal control. Early manipulation of the area of disease increases the risk of thromboembolic events, as shown by transcranial Doppler studies. Dissecting the proximal and distal vessels away from the diseased area minimizes the risk of intraoperative stroke. An occluded contralateral carotid is a risk factor for endarterectomy. An intact contralateral carotid artery and circle of Willis does not increase stroke risk. Symptomatic carotid lesions have a higher stroke risk than asymptomatic lesions. In a large study, it was shown that surgeons who perform 10 to 15 CEAs per year have better outcomes than those who perform fewer than 5 procedures annually. * 3.) Which of the following statements is true regarding use of iodinated contrast? Increased risk of contrast-induced nephropathy in diabetics Nephrogenic systemic fibrosis in patients with renal insufficiency Greater rate of allergic response for non-ionic contrast than ionic contrast Higher risk of allergic reaction if the patient has had a vasectomy Show answerThe correct answer is 1, Increased risk of contrast-induced nephropathy in diabetics. Diabetics have a higher risk of contrast-induced nephropathy than nondiabetics. Nephrogenic systemic fibrosis occurs with gadolinium agents. Ionic contrast confers a risk of reaction from 4% to 12%, while non-ionic contrast will result in a reaction in 1% to 3% of the cases. Patients are at greater risk of an adverse reaction to protamine if they have had a vasectomy, but this has no association with iodinated contrast. * 4.) Which of the following is the best initial treatment of mild contrast extravasation after superficial femoral artery angioplasty? Open surgical repair with femoral distal bypass Low pressure prolonged angioplasty Popliteal artery sheath placement for through-and-through access Placement of balloon-expandable stent Show answerThe correct answer is 2, Low pressure prolonged angioplasty. The initial maneuver when a mild contrast extravasation occurs is prolonged low pressure angioplasty. In many cases, this is definitive therapy. It also provides an opportunity for volume optimization and preparation for covered self-expanding stents, if unsuccessful. Open repair with or without bypass is not an initial treatment, and is used when endovascular options fail. Obtaining popliteal access when a perforation has occurred is time-consuming and would not allow for treatment while continued bleeding is occurring. Balloon-expandable stents have worse outcomes than self-expanding stents in the superficial femoral artery, and a noncovered stent would not resolve the perforation. * 5.) Which of the following statements regarding infrainguinal bypass is correct? May have wound complications in up to 45% of cases Has a lower wound infection rate than axillofemoral bypass Infection of prosthetic bypass to the graft can be managed with local wound care May be complicated by early graft thrombosis in 15% of cases Show answerThe correct answer is 1, May have wound complications in up to 45% of cases. Infrainguinal bypass procedures, with a groin and distal incision, have the highest rate of infectious complications, ranging from 15% to 45%. Isolated groin incision complications, such as with axillofemoral bypasses, are less frequent, at 10%. Conservative management of wound infections is an option, but in cases where prosthetic graft is involved, an exposed removal is necessary. The overall risk of early graft thrombosis is approximately 5%, with increased incidence in high-risk conduits.