A 72-year-old woman comes to the physician for follow-up care. One year ago, she was diagnosed with a 3.8-cm infrarenal aortic aneurysm found incidentally on abdominal ultrasound. She has no complaints. She has hypertension, type 2 diabetes mellitus, and COPD. Current medications include hydrochlorothiazide, lisinopril, glyburide, and an albuterol inhaler. She has smoked a pack of cigarettes daily for 45 years. Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 12/min, and blood pressure is 145/85 mm Hg. Examination shows a faint abdominal bruit on auscultation. Ultrasonography of the abdomen shows a 4.9-cm saccular dilation of the infrarenal aorta. Which of the following is the most appropriate next step in management?

Elective endovascular aneurysm repair

Adjustment of cardiovascular risk factors and follow-up ultrasound in 12 months

Adjustment of cardiovascular risk factors and follow-up ultrasound in 6 months

Adjustment of cardiovascular risk factors and follow-up CT in 6 months

A 27-year-old soldier stationed in Libya sustains a shrapnel injury during an attack, causing a traumatic above-elbow amputation. The resulting arterial bleed is managed with a tourniquet prior to transport to the military treatment facility. On arrival, he is alert and oriented to person, place, and time. His armor and clothing are removed. His pulse is 145/min, respirations are 28/min, and blood pressure is 95/52 mm Hg. Pulmonary examination shows symmetric chest rise. The lungs are clear to auscultation. Abdominal examination shows no abnormalities. There are multiple shrapnel wounds over the upper and lower extremities. A tourniquet is in place around the right upper extremity; the right proximal forearm has been amputated. One large-bore intravenous catheter is placed in the left antecubital fossa. Despite multiple attempts, medical staff is unable to establish additional intravenous access. Which of the following is the most appropriate next step in management?

Perform endotracheal intubation

Establish central venous access

Replace the tourniquet with a pressure dressing

One and a half hours after undergoing an elective cardiac catheterization, a 53-year-old woman has right flank and back pain. She has hypertension, hypercholesterolemia, and type 2 diabetes mellitus. She had an 80% stenosis in the left anterior descending artery and 2 stents were placed. Intravenous unfractionated heparin was used prior to the procedure. Prior to admission, her medications were enalapril, simvastatin, and metformin. Her temperature is 37.3°C (99.1°F), pulse is 102/min, and blood pressure is 109/75 mm Hg. Examination shows a tender lower abdomen; there is no guarding or rigidity. There is right suprainguinal fullness and tenderness. There is no bleeding or discharge from the femoral access site. Cardiac examination shows no murmurs, rubs, or gallops. Femoral and pedal pulses are palpable bilaterally. 0.9% saline infusion is begun. A complete blood count shows a hematocrit of 36%, leukocyte count of 8,400/mm3, and a platelet count of 230,000/mm3. Which of the following is the most appropriate next step in management?

CT scan of the abdomen and pelvis

Administer intravenous atropine

A 55-year-old man comes to the emergency department because of left-sided chest pain and difficulty breathing for the past 30 minutes. His pulse is 88/min. He is pale and anxious. Serum studies show increased cardiac enzymes. An ECG shows ST-elevations in leads I, aVL, and V5-V6. A percutaneous coronary intervention is performed. In order to localize the site of the lesion, the catheter must pass through which of the following structures?

Left coronary artery → left circumflex artery

Right coronary artery → posterior descending artery

Left coronary artery → left anterior descending artery

Right coronary artery → right marginal artery

Left coronary artery → posterior descending artery

A 33-year-old woman comes to the emergency department because of severe right flank pain for 2 hours. The pain is colicky in nature and she describes it as 9 out of 10 in intensity. She has had 2 episodes of vomiting. She has no history of similar episodes in the past. She is 160 cm (5 ft 3 in) tall and weighs 104 kg (229 lb); BMI is 41 kg/m2. Her temperature is 37.3°C (99.1°F), pulse is 96/min, respirations are 16/min and blood pressure is 116/76 mm Hg. The abdomen is soft and there is mild tenderness to palpation in the right lower quadrant. Bowel sounds are reduced. The remainder of the examination shows no abnormalities. Her leukocyte count is 7,400/mm3. A low-dose CT scan of the abdomen and pelvis shows a round 12-mm stone in the distal right ureter. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows RBCs and no WBCs. 0.9% saline infusion is begun and intravenous ketorolac is administered. Which of the following is the most appropriate next step in management?

Extracorporeal shock wave lithotripsy

A 36-year-old man comes to the emergency department 4 hours after a bike accident for severe pain and swelling in his right leg. He has not had a headache, nausea, vomiting, abdominal pain, or blood in his urine. He has a history of gastroesophageal reflux disease and allergic rhinitis. He has smoked one pack of cigarettes daily for 17 years and drinks an average of one alcoholic beverage daily. His medications include levocetirizine and pantoprazole. He is in moderate distress. His temperature is 37°C (98.6°F), pulse is 112/min, and blood pressure is 140/80 mm Hg. Examination shows multiple bruises over both lower extremities and the face. There is swelling surrounding a 2 cm laceration 13 cm below the right knee. The lower two-thirds of the tibia is tender to palpation and the skin is pale and cool to the touch. The anterior tibial, posterior tibial, and dorsalis pedis pulses are weak. Capillary refill time of the right big toe is 4 seconds. Dorsiflexion of his right foot causes severe pain in his calf. Cardiopulmonary examination is normal. An x-ray is ordered, which is shown below. Which of the following is the most appropriate next step in management?

Open reduction and internal fixation

A 59-year-old patient comes to the emergency department accompanied by his wife because of severe right leg pain and numbness. His condition suddenly started an hour ago. His wife says that he has a heart rhythm problem for which he takes a blood thinner, but he is not compliant with his medications. He has smoked 10–15 cigarettes daily for the past 15 years. His temperature is 36.9°C (98.42°F), blood pressure is 140/90 mm Hg, and pulse is 85/min and irregular. On physical examination, the patient is anxious and his right leg is cool and pale. Palpation of the popliteal fossa shows a weaker popliteal pulse on the right side compared to the left side. Which of the following is the best initial step in the management of this patient's condition?

Urgent assessment for amputation or revascularization

Oral acetaminophen and topical capsaicin

Endovascular procedures overview for USMLE Step 2 CK: High-Yield Surgery Lessons

🔩 Core Principles - Wires & Wonders

The foundation of endovascular access is the Seldinger Technique, enabling percutaneous entry into a vessel.

1. Needle: Puncture the target vessel.
2. Guidewire: Pass through the needle into the lumen.
3. Sheath/Catheter: Advance over the wire; remove wire.

Essential Toolkit:

Guidewires: Provide a "rail" for device delivery.
Sheaths: Maintain access, prevent bleeding.
Catheters: For angiography or device passage.
Balloons/Stents: For angioplasty (PTA) & scaffolding.

Seldinger technique for vascular access

⭐ High-Yield: The common femoral artery (CFA) is the most frequent access site. Puncture should be over the femoral head to allow effective compression and minimize retroperitoneal hemorrhage risk.

🗺️ Anatomy - Vascular Superhighways

Primary Arterial Access: Common Femoral Artery (CFA) is the workhorse.
- Location: Below inguinal ligament, over the femoral head.
- 📌 Mnemonic (Lateral to Medial): NAVEL (Nerve, Artery, Vein, Empty space, Lymphatics).
Alternative Arterial Access:
- Upper Extremity: Radial, Brachial arteries (e.g., cardiac cath, upper extremity pathology).
- Lower Extremity: Popliteal, Tibial arteries (for distal leg interventions).
Primary Venous Access:
- Common Femoral Vein (medial to CFA).
- Internal Jugular Vein (especially for IVC filters, central lines).

Femoral artery access site for endovascular procedures

⭐ High-Yield: The ideal CFA puncture is over the femoral head. This bony backstop allows effective compression. Puncturing above the inguinal ligament risks a non-compressible, life-threatening retroperitoneal bleed.

🛠️ Management - Plumbing a New Way

Core Principle: Minimally invasive procedures performed within the vascular system, primarily via percutaneous access (e.g., common femoral artery).
Foundation: Seldinger technique (needle → guidewire → sheath) for safe vessel access.
Imaging: Fluoroscopy with iodinated contrast is essential for real-time visualization.

Common Interventions:

Angioplasty (PTA): Balloon inflation to dilate stenotic vessels (e.g., PAD).
Stenting: Metallic scaffold to maintain patency. Drug-eluting stents (DES) release antiproliferative agents to ↓ restenosis vs. bare-metal stents (BMS).
Atherectomy: Mechanical plaque removal (cutting, grinding, laser).
Embolization: Occluding vessels (e.g., GI bleed, trauma) with coils or particles.
Thrombectomy/Thrombolysis: Mechanical removal or pharmacological dissolution of acute clots.
EVAR/TEVAR: Endovascular repair of abdominal/thoracic aortic aneurysms using stent-grafts.

⭐ EVAR has lower peri-operative mortality than open AAA repair but requires lifelong surveillance imaging to detect endoleaks (persistent blood flow into the aneurysm sac).

Endovascular aneurysm repair (EVAR) stent graft diagram

⚠️ Complications - When Wires Go Wrong

Access Site:
- Hematoma/Bleeding: Most common.
- Pseudoaneurysm: Pulsatile mass with systolic bruit. 💡Dx with duplex US.
- AV Fistula: Continuous "machinery" bruit.
- Retroperitoneal Hemorrhage: High femoral stick (above inguinal ligament) → hypotension, flank pain, ↓Hct.
Intra-procedural:
- Dissection: Guidewire creates a false lumen.
- Perforation: Can cause hemorrhage or tamponade.
- Thrombosis: Acute occlusion at the treatment site.
- Distal Embolization: Atheroemboli ("trash foot"/blue toe syndrome) or thromboemboli causing acute limb ischemia.

⭐ Suspect retroperitoneal hemorrhage with post-procedure hypotension and flank pain, even with a normal groin exam. Confirm with a non-contrast CT of the abdomen/pelvis.

⚡ Biggest Takeaways

Endovascular procedures are minimally invasive, using catheters via the common femoral artery.

Key interventions include angioplasty (PTA), stenting, and Endovascular Aneurysm Repair (EVAR/TEVAR).

Major risks: access site complications (retroperitoneal hemorrhage, pseudoaneurysm) and contrast-induced nephropathy.

Distal embolization ("trash foot" or blue toe syndrome) can result from dislodged atheromatous plaque.

Endoleaks are a unique EVAR complication; Type II (collateral back-bleeding) is the most common.

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