Ex2 Vascular Dx Flashcards by Rachel Unknown

Thoracic/Abdominal aorta is most often

aneurysmal

outpouch of tissue (all 3 layers) that fills with blood
50% increase in diameter

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TAA - rupture - survival rate

25%

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TAA - dissection: initiating event

tear in intima

-forms false channel

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TAA - dissection most commonly happens in

thorax in the ascending aorta

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most common risk factors in TAA

80% - Atherosclerosis
19% - family hx of aneurysmal dx
Smoking, Male, Older age, HTN

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Inherited disorders assoc. with TAA

Marfans Syndrome
Ehler’s Danlos syndrome
(ED syn: flexible joints, skin elastic skin, bruise easily)
Bicuspid aortic valve

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marfans syndrome

hereditary connective tissue disorder 
Fibrilin-1 gene - matrix destruction 
CHEMICAL function (not mechanical) - causes structural weakness in aorta

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Bicuspid aortic valve

most common congenital anomaly resulting in aortic dissection/dilation

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Crawford Classification Type I

All/most of descending thoracic aorta + upper abdominal aorta

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Crawford Classification Type II

All/most of descending thoracic aorta + most of abdominal aorta

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Crawford Classification Type III

Involves lower portion + abdominal aorta

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Crawford Classification Type IV

Most of abdominal aorta including visceral segment

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Most difficult TAA to treat

Crawford II + III

*crosses diaphragm

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Dissecting aneurysms are classified by

Debakey Classification

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Debakey I

formed a false track all the way up/down entire length of aorta

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Debakey II

Tear = ascending

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Debakey IIIa

Tear = intimal + stays on descending aorta

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Debakey IIIb

Tear = intima + entire length of that side

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S/S TAA

Asymptomatic

*impingement of aneurysm on adjacent structure may cause symptomatology on assoc. location

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TAA with s/s hoarseness

impingement on R laryngeal nerve

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TAA with s/s stridor

Compression of trachea

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TAA with dysphagia

compression of esophagus

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TAA with facial edema

compression of superior vena cava

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S/S TAA dissection

acute, severe, sharp pain in anterior chest, neck or between shoulder blades

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TAA dissection presents with shock

(severe hypotension) -prognosis = poor decreased peripheral pulses

Complications of TAA dissection

stroke, ischemic peripheral neuropathy, paraplegia, MI, GI ischemia, renal artery obstruction *cardiac tamponade

Diagnosis of TAA

CXR (widening mediastinum) | TE-Echo + doppler flow (highly sensitive+specific)

predictors of post-thoracic aorta surgery

predictors of resp failure: | Smoking + COPD

Tx TAA

``` Surgical repair Type A Ascending aorta Aorta Arch Type B if aneurysm > 5cm Medical Tx: Type B < 5cm ```

Type A Dissection

Ascending aorta +/- arch

Mortality: Type A Dissection

27% after repair | 56% if not repaired

Type B dissection

Ascending aorta NOT involved

Ascending + aortic arch dissection

emergent/urgent surgery

TAA - which is associated with better outcomes?

Type B: Descending thoracic aortic dissection

Which TAA requires cardiopulmonary bypass?

Aortic Arch +hypothermia +circulatory arrest *neurological deficits post repair

Most important risk of paraplegia/renal failure with aortic cross clamping

Duration of clamping aorta | *under 30 minutes = almost no paraplegia

Risks assoc.: surgical resection of thoracic aortic aneurysm

``` spinal cord ischemia MI/HF coagulopathy renal failure 30% respiratory failure 50% ```

Lower 2/3 of spinal cord is supplied by

Artery of Adamkiewicz (AAA) Ischemia: Anterior spinal artery syndrome

HD response to X clamping

Increased BP, SVR, preload (CVP, PAOP, LVED), CSF pressure, myocardial contractility, coronary blood flow *no increase in HR means: decreased CO

Tx - increase CO from X-clamp

Vasodilators: SNP, NTG

Tx goal during X-clamp

Myocardial preservation | -decrease afterload, normalize preload, coronary blood flow, contractilty

Blood flow distal to clamp depends on

perfusion pressure

HD response to unclamping

decrease in SVR/BP LVEDV decreases CO changes - unclear myocardial blood flow increases

Goal during unclamping

Gradual decrease to avoid hypotension (metabolic waste/lactate buildup)

Monitoring during TAA cross clamping

R radial A line | Femoral Artery A line

Cerebral perfusion during TAA cross clamping is monitored via

R radial A line

Renal/spinal cord perfusion during TAA cross clamp is monitored via

femoral artery A line

Goal MAP above X-clamp

100mmHg

Goal MAP below X-clamp

> 50 mmHg

Monitor neurologic function during X-clamp

via SSEPs

Monitor cardiac fxn during x-clamp via

TEE, pulm artery catheter

How is renal protection performed in X-clamp for TAA?

40 Celsius LR + 25g mannitol/L directly into renal artery via surgeon

post op management TAA

epidural analgesia: neuraxial opioids | do NOT want LA in epidural (masks anterior artery spinal syndrome)

What is common and must be managed in post-op of TAA X-clamp?

HTN | Tx: NTG, SNP, labetalol, hydralazine, BB

Tx AAA

surgery if AAA > 5.5 cm Serial U/S: < 5.5 cm if increasing in size >.6-.8 cm/year, surgery indicated Smoking + close to threshold: surgery indicated

Preop evaluation for AAA

- optimize comorbid conditions - copd: minimize resp infxn, etc. - caution in severe resp/renal dysfxn

#1 cause of post-op deaths (AAA)

Classic triad of ruptured AAA

Hypotension Back pain Pulsatile mass

Ruptured AAA - tx depends on

stable/unstable/suspected rupture

Ruptured AAA - tx if stable

- exsanguination may be prevented by clotting + tamponade effect of retroperitoneum - euvolemic resuscitation deferred

ruptured AAA - tx if unstable

- require immediate surgical intvn - give uncrossed/unmatched blood - no time to optimize preop conditions

ruptured AAA - tx if suspected rupture

same as unstable

AAA - invasive monitoring during surgery

PA catheter Echo - assess response during/after X-clamp GETA - benzo + narcotic

AAA - when is epidural safe?

If PLANNED AAA repair

Risk of AAA + TAA repair post-op

spinal cord injury | -from 12h-21d

AAA vs. TAA main intra-op difference

AAA: need DL ETT

Ex2 Vascular Dx Flashcards

(66 cards)