3 arteries that branch from aortic arch?
brachiocephalic
left common carotid
left subclavian
4 arteries (2 pairs) that supply blood to the Circle of Willis
left and right common carotids
left and right internal carotids
acute arterial disease?
occlusion, embolitic disease, plaque rupture, thrombosis
2 options to treat acute arterial occlusion
embolectomy
thrombolytic medication (heparin)
six “P’s” that indicate acute arterial occlusion
pain
pallor
pulselessness
paresthesia
paralysis
poikilothermia
chronic arterial disease?
calcium and cholesterol within the wall of an artery
define arteriosclerosis
aging process
hardening/thickening of arteries
too much pressure
define atherosclerosis
pathologic process (type of arteriosclerosis)
buildup of fats, cholesterol, plaque
calcification
athero vs. aterio sclerosis
arterio - aging, high BP, hardening
athero - pathologic, plaque
define atheroma
deposit of plaque in an artery
define aneurysm
local abnormal dilation of a blood vessel
structural weakening of the intima
pseudoaneurysm
false
disruption of all vessel layers
arterial blood collects in perivascular tissue
dissecting aneurysm
tear allowing blood to dissect between vessel layers
fusiform aneurysm
spindle shaped
complete circumferential involvement of artery
saccular aneurysm
sac with a narrow neck on side of artery
define intermittent claudication
muscle cramping during exercise
intermittent claudication indicates?
vascular disease in aortoiliac vessels and distal arteries
lower extremity PAD
not enough O2 distal to obstruction
define rest pain
pain in the foot at rest
no O2
rest pain indicates?
critical ischemia
ulcers
gangrene
CVA
cerebrovascular accident
define stroke/CVA
infarction of brain tissue due to lack of blood
TIA
transient ischemic attack
define transient ischemic attack
temporary localized reduction of blood floow (O2) to brain
less than 24 hrs
causes of TIA
atheromatous debris
thromboembolism from a carotid
fix TIA?
carotid endarterectomy
acute venous disease (DVT)
clot in deep venous system (lower extremity)
endothelial injury
venostasis
hyper coagulability
DVT symptoms
limb swelling
pain
skin color change
danger of DVT
emboli to right ventricle then lungs (fatal)
2 noninvasive imaging procedures to diagnose
MRI
doppler/ultrasound
angiography
injection of dye into venous and arterial systems
diagnose AV malformation, aneurysm, tumors, stenosis, vascular accidents
arteriography
injection of dye in the arterial system
diagnose AV malformation, aneurysm, tumors, stenosis
venography
x-ray of veins with dye
diagnose blood clots in legs and abdomen, DVT
why do angiography or venography?
diagnose problems in arterial and venous systems intraoperatively
describe doppler
change in frequency of echo signals when there is a change in distance
ultrasound beam reflected by moving RBC
why do we use doppler?
information by sound, graph, spectral analysis
advantages of doppler
available
easy
inexpensive
why use water-soluble gel on intact skin
conduction
doppler signal of a healthy artery
biphasic or triphasic
systole then early diastole, late diastole
doppler signal of an unhealthy artery
low pitched, monophasic
unhealthy doppler indicates?
stenosis or occlusion
bruit
low pitched blowing sound
heart at points of severe stenosis
bruit indicates?
vessel stenosis
CVP lines
catheter in the right internal jugular vein
why use a CVP line?
assessment of blood volume and vascular tone
umbilical tape/vessel loops in vascular
retraction and vessel control
preferred suture material for vascular anastomosis
synthetic monofilament nonabsorbable 0 to 10-0
double armed
pledget
preferred suture names in vascular
prolene
dacron
polyester
PTFE
why is the preferred suture material used
strong
pass through vessel walls easily
little trauma
pledget
small piece of teflon used to buttress under suture
why use pledgets?
over arteriotomy site
bleeding through needle hole in major vessels
friable tissue
systemic anticoagulation drug
heparin
why anticoagulate in vascular?
prevents clots
prevents thromboembolitic event before placing a clamp
reverse systemic anticoagulation
protomine sulfate
why use hep saline?
irrigation of lumen/shunt
drug to prevent spasm in harvested autologous vein grafts?
papaverine
why use hemostatic agents?
promote adhesion of platelets
absorbable gelatin sponge (Gelfoam)
mechanical hemostasis
apply to bleeding surface (forms matrix)
contraindicated in infection
absorbable collagen (Avitene, Hemopad, Helistat)
seals anastomosis
chemical/mechanical hemostasis
form fibrin
contraindicated in infection
oxidized cellulose (Surgicel, Oxycel)
dry mechanical hemostasis
fibrin glue
fibrin patch seals anastomosis
w/cryo, bovine thrombin, calcium chloride
topical thrombin
chemical hemostasis
3 most common and serious complications in vascular
infection
hemorrhage
thrombi/embolism
3 types of venous conduits for bypass grafting
reversed
non-reversed
in-situ
reversed venous conduit
valves reversed so blood isnt obstructed
in-situ venous conduit
lower extremity
reverses blood flow
disrupts intimal valves
anastomosis distally and proximally
non-reversed venous conduit
renal
mesenteric
in-situ vs. reversed vein grafts
in-situ: valves need to be stripped (less invasive)
reversed: no stripping of valves
4 synthetic graft materials
Dacron knitted polyester: porous allows fibrous tissue to ingrow
Dacron woven polyester: leakproof
filamentous velour: porous, knee joint, crimped or not
PTFE: lattice, cells grow
pros and cons of the 4 graft materials
knitted polyester: hypothrombogenic flow surface
woven polyester: leakproof, only for aortic replacement/bypass
filamentous velour: leakproof, antibiotic
PTFE: stable, antibiotic, seeded endothelial cells
which grafts must be preclotted?
Dacron: knitted polyester
filamentous velour
why preclot?
wall of graft becomes impervious to blood
how to preclot?
soak in patient’s own blood before systemic heparinization
PTA
percutaneous transluminal angioplasty
percutaneous transluminal angioplasty
local/fluoroscopy needle into artery
endovascular device placed
common iliac for stenosis
why perform PTA
severe ischemia/claudication
localized or segmental stenosis of common iliac
balloon angioplasty
dilation endovascular catheter
displace plaque against walls when inflated
intraluminal stenting
stent placed after balloon angioplasty
laser angioplasty
laser destroys plaque
supplements balloon angioplasty
atherectomy
catheter mounted instruments for transluminal removal of plaque
rotating cam, burr, side cutter
fluoroscopic guidance
emoblectomy/thrombectomy
invision into an artery to remove plaque
why perform embolectomy/thrombectomy
remove thromboembolitic material and restore blood flow
fogarty balloon catheter
inserted proximally
advanced distally past obstruction
inflated and pulled out w/plaque
solution that inflates balloon catheter
.5-2ml hep saline
embolus
thrombus broken free and moved towards the brain
thrombus
solid mass formed locally
thrombolytic therapy
bolus or x-ray catheter into vessel with thrombus for 24-72 hrs
breaks up clots
3 agents in thrombolytic therapy
streptokinase
urokinase
tissue type plasminogen activator
vena cava filter insertion
endovascular filter in right jugular or femoral vein (vena cava)
fluoroscopic placement
purpose of vena cava filter insertion
prevent emboli from traveling to the lungs
Mobin-Uddin umbrella and Greenfield filters
Mobin: permanent, cone shaped titanium, below renal veins
Greenfield: permanent, clots larger than 3mm, cone shaped titanium, below renal veins
AAA
abdominal aortic aneurysmectomy
AAA procedure
surgical obliteration of the aneurysm w/ or w/o iliac arteries
graft to maintain continuity
position & incision for AAA
supine
midline from xiphoid process to symphysis pubis
2 self-retaining abominal retractors in AAA
Bookwalter
Omnitract
3 vascular clamps for aortic occlusion
DeBakey
Statinsky
Fogarty
why mark pedal pulses pre-op?
rapid access
must be checked intra-op
doppler
Mannitol/Lasix in aortic clamping
prevent ischemic renal failure
preserve kidney function
AAA complications
hemorrhage
ischemic organs
injury to organs nearby
renal failure
most common cause of AAA
atherosclerosis
where are most AAAs found?
abdominal aorta
between renal arteries and aortic bifurcation
declamping shock?
severe hypotension after declamping aorta
2 methods of graft insertion
open inclusion: graft inside aneurysm with the sac closed over it
open exclusion: graft placed beside unopened aneurysm sac
carotid endarterectomy
remova of atheroma at carotid bifurcation to increase cerebral perfusion
why perform carotid endarterectomy?
increase cerebral perfusion
decrease stroke/embolization
head position for carotid endarterectomy
supine with head turned away from operative site
neck hyperextended
2 methods of anesthesia in carotid endarterectomy
general: needs EEG
cervical plexus block: patient provides info
why use a shunt in carotid endarterectomy?
continuous blood flow to brain intra-op
2 shunts in carotid endarterectomy
Javid
Argyle
order of clamp removal in carotid endarterectomy
external, common, internal
why is there a clamp removal sequence?
make sure no debris goes up the internal carotid to the brain
self-retaining retractor in carotid endarterectomy
weitlaner
instrument to make initial arteriotomy
11 blade on a #7 handle
instrument to extend arteriotomy
potts angulated scissors
femoral-popliteal and femoral-tibial bypass
restore blood flow to leg by bypassing the femoral, popliteal, or tibial arteries
position for fem-pop or fem-tib
supine
hip externally rotated and abducted
knee flexed
self-retaining retractor for groin incisions
Gelpi
Garrett
Weitlaner
why use a tunneler?
tunnel graft under the skin
fem-pop in situ
bypass femoral artery with saphenous vein
incise venous valves/tributaries
fem-pop in situ advantages and contraindications
increased graft availability and patency
varicose veins
previous saphenous stripping/ligation
instruments used to incise intimal valves
microvascular scissors
valvulotome
leather in situ valve cutter
femorofemoral bypass
extranatomic (unusual) bypass to restore blood to one leg
why is femorofemoral bypass performed?
when inflow is needed but an aortic procedure needs to be avoided
where is a femorofemoral graft placed?
subcutaneously acorss the symphysis pubis
what graft is used for a femorofemoral graft?
Dacron
PTFE
what is axillofemoral bypass?
subQ placement of a prosthesis
axillary artery to femoral artery on same side
define amputation
partial or complete removal of a limb
why perform amputation?
ischemia
gangrene
narcotic, infected tissue
trauma
malignancy
2 most frequently performed amputations
above the knee
below the knee
define fasciotomy
cutting away fascia to release pressure
why perform fasciotomy
decompression to prevent compartment syndrome
after acute ischemia of an extremity
describe varicose vein ligation/stripping
removing or tying off saphenous vein and branches
why perform varicose vein ligation/stripping?
remove diseased veins to prevent:
ulcers
edema
pain
fatigue
what vein is excised in varicose vein ligation/stripping
saphenous
instrument used in varicose vein procedures?
semiflexible stripping device
dressing post-op varicose vein procedure?
cotton elastic bandage for compression
define AV fistula (native)
direct connection w/ patient’s own vessels
define AV fistula (bridge)
v-shaped for vessels close to each other
dialysis, no maturation
PTFE graft
why create AV fistulas?
long-term dialysis
allows vein to be punctured with large bore needles
Brescia-Cimino fistula
anastomosis of radial artery and cephalic vein
basic principle governing fistula placement
start distal arm and move proximally with following fistulas
common vessels for AV fistula
radial artery
cephalic vein
ulnar artery-basalic vein
brachial artery-brachial/cephalic
define arterialize (mature) a vein
thicken wall to withstand pressure
how long does it take an AV fistula to mature?
3 weeks
most common complications with AV fistulas
stenosis
venous hypertension
aneurysm
infection
congestive heart failure
describe a portosystemic shunt
shunt between portal system (liver) and systemic venous systems
why create a portosystemic shunt?
decompress esophageal varices
prevent hemorrhage
relieve pain
goal of portosystemic shunt
palliative
reduce portal hypertension/portal venous flow
3 types of portosystemic shunts
Warren/distal splenorenal
mesocaval
postcaval
Warren/distal splenorenal (porto)
anastomosis of splenic vein-left renal vein
mesocaval (porto)
superior mesenteric vein to inferior vena cava
postcaval (porto)
end to side or side to side of portal vein and inferior vena cava
interposition H graft
describe coronary artery disease
stenosis or obstruction of coronary arteries
occlusive/ischemic heart disease
myocardial infarction
describe angina pectoris
ischemic chest pain
fatigue
syncope
dyspnea
myocardial infarction
heart attack
death or injury to the myocardium resulting from occlusion or atherosclerotic lesions
describe coronary artery bypass grafting
arterial bypass on cardiopulmonary bypass
common vessels for CABG
internal mammary artery
greater saphenous vein
radial artery
percutaneous transluminal coronary angioplasty
fluoroscopy w/ image intensification balloon dilation of coronary arteries
significant atheroscletoric plaque
percutaneous transluminal coronary artery stenting
stent pushes plaque against the wall
permanent
why use induced hypothermia in open-heart
reduction in O2 consumption
myocardial protection in long cases
define cardioplegia
reduce O2/energy needs
potassium
define cerebroplegia
protection by infusing O2 blood to the brain
antegrade into right common carotid
retrograde in superior vena cava
describe circulatory arrest
all blood flow stopped, cooled to 18C, bypass turned off
creates a dry field when the aorta can’t be clamped off
heart-lung bypass process
oxygenation and circulation
systemic heparinization
cannulas
lungs deflated and immobilized
cannula placement for CPB
venous in superior and inferior vena cava
to machine
back in ascending aorta or femoral artery
semi-lunar valves
aortic-left ventricle to aorta
pulmonary-right ventricle to pulmonary artery
atrioventricular valves
mitral/bicuspid-left
tricuspid-right
blood flow through heart
right atrium > tricuspid > right ventricle > pulmonary valve > lungs > pulmonary veins > left atrium > mitral > left ventricle > aortic > aorta > systemic
systole and diastole
systole: contracts to pump blood into arteries
diastole: relaxes to allow chambers to fill
3 primary coronary arteries
left anterior descending
circumflex
right coronary artery
describe the coronary sinus
posterior coronary sulcus empties in right atrium
cardiac venous blood return
impulse conduction in heart
SA node (perkinje) > AV node > bundle of His
AV node is atrium to ventricle communication
epicardium
visceral pericardium: outermost slippery serous mesothelium
myocardium
middle layer, thickest, 95%
cardiac muscle functional syncytium
endocardium
innermost endothelium
lines valves and chambers
minimize friction and prevents blood clots
pericardial sac
anchors, protects, friction free movement
fibrous, serous: parietal, visceral
ribs in thoracic cage?
12 pairs
7 true
5 false
parts of the sternum
manubrium
gladiolus
xiphoid process
4 most common thoracotomy incisions
posterolateral
thoracoabdominal
anterolateral
median sternotomy
posterolateral incision
nipple to ribs to spine
thoracoabdominal incision
axillary to abdomen
anterolateral incision
below breast to axillary line
median sternotomy
vertical suprasternal notch to xiphoid process
3 chest spreaders/rib retractors
Burford
Finochietto
Baily spreader
baily rib approximator
post thoracotomy to help close ribs
define hemoptysis
coughing up blood from lungs/airway in sputum
define hemothorax
blood in pleural cavity
define pneumothorax
collapsed lung, air in pleural space
define atelectasis
collapse of part or all of the lung
pericardectomy
partial excision of thick, adhered pericardium to relieve constriction
restricts diastolic filling
thoracentesis
remove fluid from pleural space
needle in chest wall w/ ultrasound
bronchoscopy
visualize trachea, bronchi, lungs
diagnostic, remove foreign body, small tumor, biopsy
bronchoscopy position
supine or sitting
head to right to see left
head to left to see right
3 lobes or 2 lobes? (lungs)
right has 3
left has 2
define empyema
pus in pleural cavity
define pleural effusion
buildup of fluid in pleural cavity
treat chronic empyema/pleural effusion
thoracentesis
thoracostomy
describe talc pleurodesis/poudrage
using chemical sclerosing agent to remove the space
fusion of pleural layers prevents serous production and accumulation
describe pulmonary decortication
membrane stripping removes a restrictive layer over lung
re-expand lung and fill space after drainage
why use a double-lumen ET tube in thoracic
expand unaffected lung
collapse surgical lung
define vital capacity
max air expelled after max inhalation
3-5 liters
define tidal volume
resting respiration
air inhaled OR exhaled
.5 liters
define residual volume
air in lungs after max exhalation
cannot expel
1.2 liters
describe the thoracic outlet
manubrium anteriorly, 1st rib anterolaterally, 1st thoracic vertebra posteriorly
subclavian artery/vein, vertebral artery, brachial plexus pass through
thoracic outlet syndrome
change in anterior/middle scalene muscle causes intermittent pressure/pain/paralysis of an upper extremity
treat thoracic outlet syndrome
scalenectomy
scalenotomy
rib resection
pectus excavatum
funnel chest: deep depression of the chest
posterior displacement of sternum
pectus carinatum
pigeon chest: protrusion of the chest over the sternum
patent ductus arteriosus
fetal ductus anteriosus doesn’t close (connects pulmonary artery to aorta)
ligation
division of the ductus
atrial septal defect/ventricular septal defect
ASD: hole in interatrial septum
VSD: hole in intraventricular septum
primary closure
synthetic patch
bovine patch
coarctation of the aorta
localized constriction of the aortic arch
hypertension up
hypotension down
treat coarctation of the aorta
anastomosis w/ resection
pericardial or synthetic patch
tetralogy of Fallot
anterior malalignment of the infundibular septum w/ muscular septum
VSD, right ventricular hypertrophy, subpulmonic stenosis, aortic override of the ventricular septum
myasthenia gravis
autoimmune neuromuscular
removal of thymus
define dyspnea
painful/difficult breathing
pneumonectomy
excision of an entire lung for malignant neoplasm or extensive unilateral pulmonary disease
posterolateral incision
lobectomy
one or more lobes removed
neoplasm confined to lobe
posterolateral incision
segmental resection
removal of individual bronchovascular section
pathologic process confined or acute hemorrhage
wedge resection
remove a wedge with no concern about lobes
benign lesion, margins or peripheral lobe
mediastinoscopy
mediastinal lymph nodes for biopsy
assessment of resectability for patients w/ bronchogenic carcinoma or lesions
mediastinum
heart
esophagus
thymus/thoracic duct
trachea, bronchi, lymph nodes
principle complication with mediastinoscopy
major bleeding
ICD implantation
transvenous/endoacardial implanted in subQ pocket in chest wall (generator)
epicardial in abdomen
ICD
electrodes sense ventricular tachycardia or fibrillation
shock to normal rhythm
cardiac resynchronization therapy
leads placed in right atrium and ventricle
left ventricle pacing done with an electrode in coronary sinus/vein to left heart
r+l ventricles pump and AV node is synchronized
valve replacement surgery
mechanical valve mimics human valve leaflets
insufficiency
lifetime anticoagulation
rheumatic fever
untreated streptococcal infection antibodies attack heart valves
leaflets inflamed
stenosis or leaky valve
valve annuloplasty
reduction of a dilated annulus
device pulls leaflets together
valve commissuotomy
separation of the fused, adherent leaflets of the mitral valve
heparin
anticoagulant prevents clotting
protamine sulfate
reverses heparin
papaverine
vasodilation reduces vasospasm
lungs
respiration and excretion
soft, spongy, conical
bilateral in thoracic cavity/mediastinum
base/apex of lungs
apex is superior most
base is broad and flat
hilum of lungs
concavity on mediastinal surface
pulmonary root enters/exits
pleural cavity
potential space between pleura
negative pressure vacuum
prevents lung collaspe
parietal/visceral pleura
parietal: serous lining inner chest wall
visceral: serous lining outer surface of each lung
pulmonary root
primary bronchus
lymphatic vessels/nerves
bronchial arteries/veins
pulmonary arteries/veins
lung lobe
individual units of a lung
bronchopulmonary segment
smaller units of a lobe
10 in right
8 in left
bronchus
convey air into and out of the lungs
Matson rib stripper/elevator
double-ended
cutting and dissection
scrape periosteum from ribs before cutting with a shear
Duval lung forceps
grasping and holding (lung tissue)
angled or straight w/ triangular tips and horizontal serrations
Doyen rib raspatories
cutting and dissecting
scrape periosteum from ribs before cutting
c-shaped curve at the end
Farabeuf raspatory
Alexander: cutting and dissecting
scrape periosteum from ribs
double-ended blade, straight and curved
endocardial/myocardial leads
endocardial/transvenous: no thoracotomy, fluoroscopy
epicardial: thoracotomy/stenotomy in ventricular myocardium
transvenous pacemaker insertion
artial, ventricular, or both contraction
for complete heart block or bradydysrhythmias
2 types of pacemaker generators
artial
ventricular
lithium battery
mitral valve stenosis
narrowing of orifice that impedes forward blood flow
rheumatic fever
limit blood flow to l. ventricle and rise in pressure/dilation of l. atrium
mitral valve regurgitation
leaflets don’t close
blood back into l. atrium during ventricular systole
types of valve implants
mechanical: tilting disk
bio: porcine (pig), bovine (cow), equine (horse)
aortic allograft
mechanical valve
complete closure with slight regurgitation
lifetime anticoagulation
porcine valve
aortic valve from pig sutured to dacron stent/or no stent
no anticoagulation
bovine valve
pericardial onto dacron ring
no anticoagulation
equine valve
pericardial into tube into ring
no anticoagulation
select valve prosthesis
hemodynamics
thromboresistance
anatomic stability
mitral stenosis problems
pulmonary hypertension
right ventricular hypertrophy
tricuspid valve regurgitation
