Endovascular Cases

Question 1

What is a Debakey Type III?

Answer 1

Aortic dissection at the descending aorta only

Question 2

What is a Debakey Type I?

Answer 2

Aortic dissection including both ascending and descending aorta

Question 3

What is a Debakey Type II?

Answer 3

Aortic dissection involving only the ascending aorta

Question 4

What is a Stanford A?

Answer 4

Aortic dissection involving the ascending aorta

Question 5

What is a Stanford B?

Answer 5

Aortic dissection involving the descending aorta

Question 6

What is EVAR?

Answer 6

Endovascular Aortic Repair

Question 7

What is EVAAR?

Answer 7

Endovascular Abdominal Aortic Repair

Question 8

What is TEVAR?

Answer 8

Thoracic Endovascular Aortic Repair

Question 9

How much landing zone is needed for an aortic stent/graft to be placed?

Answer 9

1cm above and below

Question 10

Why would the retroperitoneal approach be used?

Answer 10

If femoral vessels are small or heavily calcified

Question 11

Which abd aortic pathologies are able to be endovascularly? Which Surgically?

Answer 11

Type A, B, C=endovascular

Type D, E=Surgical

Question 12

Over 40% of TEVAR candidates have lesions covering which arterial branch?

Answer 12

Ostium of left subclavian artery

Question 13

What must be done with a TEVAR candidate that has their left subclavian artery covered by the lesion?

Answer 13

Left Carotid-Subclavian Bypass procedure

Question 14

Which procedure is completed first in a staged elephant trunk repair?

Answer 14

Stage 1= Total arch surgical replacement

Stage 2= Endovascular repair using trunk graft as proximal landing zone

Question 15

Which Stage (1 or 2) of the Staged Elephant Trunk Procedure requires deep hypothermic circulatory arrest?

Answer 15

Stage 1

Question 16

What are indications for and elective repair of an AAA?

Answer 16

Greater than 5.0cm or growing by more than 1 cm/year

Question 17

What are indications for symptomatic aneurysms repair?

Answer 17

Repair all

Question 18

What are indications for elective repair of a TAA?

Answer 18

Greater than 5.5cm or growing greater than 3mm/year

Question 19

Can EVARs be done under MAC/sedation?

Answer 19

Patient must be able to lay supine for 1-2hrs without deep sedation d/t patient needing to hold breath for imaging

Question 20

Other than general contraindications to neuraxial blockade, what specific contraindications are there for epidurals/spinals for EVAR?

Answer 20

1. No need for TEE
2. No need for MEP or SSEPs
3. No need for COMPLETE motionless field during stent deployment.

Question 21

What specific patients may be great candidates for central neuraxial blockade versus GETA?

Answer 21

Patients with terrible lung disease that may have issues coming off ventilator

Question 22

What are 5 reasons to choose GETA for EVAR case?

Answer 22

1. Complicated- fenestrated or branched endografts
2. Planned use of TEE
3. Planned hemodynamic manipulations to create motionless field
4. Planned SSEP or MEP monitoring
5. History of difficult airway.

Question 23

Is EVAR considered high-risk surgery?

Answer 23

Yes; Patients should undergo functional testing consistent with ACC/AHA guidelines.

Question 24

What is the biggest risk during planned or unplanned hemodynamic manipulations with EVAR?

Answer 24

Acute Kidney Injury

Question 25

What are 4 reasons for AKI in EVAR cases?

Answer 25

1. Hypoperfusion/hypotension 2. Mechanical encroachment of stent graft on renal vessels 3. Emboli to the renal arteries 4. Contrast induced nephropathy

Question 26

How often does contrast induced nephropathy occur?

Answer 26

2-10% of patients

Question 27

What are four methods of reducing risk of AKI?

Answer 27

1. Ensure perioperative euvolemia 2. Maintain CO and BP 3. Limit contrast dye 4. Use Iso-osmolar/non ionic contrast dye

Question 28

What 3 medications can be used with patients that have baseline kidney disease?

Answer 28

1. N-Acetylcysteine 2. Sodium Bicarbonate 3. Statin Drugs (also steroids)

Question 29

What are 4 major causes of intra-operative hypotension/blood loss?

Answer 29

1. Iliac artery rupture 2. Accidental withdrawal of device 3. Rupture of the aortic aneurysm 4. Retroperitoneal bleeding

Question 30

Why might an EVAR patient have a lactic acidosis?

Answer 30

1. Secondary to reperfusion of lower extremities following decreased flow from cannulation

Question 31

Why might the anesthesia provider be asked to induce Vfib?

Answer 31

To limit ejection and heart to remain still for valve deployment in TAVRs and work close to the aortic valve.

Question 32

What pharmacologic treatment may the surgeon administer to treat vasospasm?

Answer 32

Nitroglycerin

Question 33

How do you calculate Spinal Cord Perfusion Pressure (SCPP)?

Answer 33

SCPP= MAP - CSF Pressure

Question 34

T/F: As CSF drainage increases through SA drain, SCPP will go down?

Answer 34

False; draining more CSF will decrease CSF pressure and therefore increase SCPP

Question 35

What is the largest arterial blood supply to the spinal cord?

Answer 35

Artery of Adamkiewicz

Question 36

Where does the Artery of Adamkiewicz arise from the aorta?

Answer 36

Typically T9-T12 (can arise from T5-L5).

Question 37

Managemant of Paraplegia following TEVAR?

Answer 37

1. Elevation of MAP >80mmHg 2. Therapeutic CSF drainage 3. Repeated neuro exam 4. Avoid abrupt cessation of CSF drainage

Question 38

What is post-implantation syndrome?

Answer 38

Early in the post-op period characterized by fever, leukocytosis, elevation of inflammatory mediators (CRP)

Question 39

Describe the 5 endoleaks:

Answer 39

``` Type I: Leaking around graft Type II: Retrograde flow from other vessles Type III: Rupture or Mis-aligned Type IV: Pressure in graft Type V: Leaking through graft ```

Question 40

T/F: Most trials show no benefit with EVAR compared to open in the short term; but long term EVAR is better?

Answer 40

False; Benefits in short term with EVAR, but by one year, they are equal

Question 41

What did the DREAM trial show?

Answer 41

Dutch Randomized Endovascular Aneurysm Management trial showed 30 day mortality rate 1.2% EVAR and 4.6% Open More equal after one year

Question 42

What plays a huge role in why EVAR cases may do better inititally?

Answer 42

Patient selection is major factor