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Vascular Flashcards

1
Q

what the 3 main arterial pathologies

A

aneurysms, dissections, occlusions

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2
Q

what vessel is most affected by aneurysms and dissections

A

aorta and its branches

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3
Q

which vessel is more likely to be affected by occlusions

A

peripheral arteries

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4
Q

aortic aneurysm is the dilation of _____ layers of artery causing a _____% increase in diameter

A

aortic aneurysm is the dilation of 3 layers of artery causing a >50% increase in diameter

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5
Q

what are symptoms of aortic anuerysm

A

asymptomatic or pain due to compression of surrounding structures

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6
Q

treatment of aortic aneursyms

A

initially treated medically to decrease expansion rate
- manage BP, cholesterol, stop smoking
- avoid strenuous exercsie, stimulants, stress
- regular monitoring for progression
- surgical when >5.5 cm diameter, growth >10 mm/year, and family Hx of dissection

aortic aneursyms rupture is associated with 75% mortality rate

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7
Q

2 types of aneurysms

A

fusiform - uniform dilation along entire circumference of arterial wall
saccular - berry shapped, bulge to one side

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8
Q

diagnostics for aortic aneurysm

A

CT, MRI, CXR, angiogram, echocardiogram

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9
Q

what is the fastest/safest way to obtain a diagnosis of aneursym in suspected dissection

A

doppler echocardiogram

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10
Q

what is an aortic disection

A

tear in the intimal layer causing blood to enter medial layer

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11
Q

symptoms of aortic dissection

A

severe sharp pain in posterior chest or back

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12
Q

diagnosis of aortic dissection

A

stable: CT, CXR, MRI, angio
unstable: ECHO

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13
Q

Standford A DIssection

ascending aorta: all patietns with acute dissection involving the ascending aorta should be considered candidates for _____

A

ascending aorta: all patietns with acute dissection involving the ascending aorta should be considered candidates for surgery

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14
Q

Standford A Dissection

the most commonly performed procedures:

A

ascending aorta & aortic valve replacement with a composite graft
replacement of the ascending aorta and resuspension of the aortic valve

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15
Q

Standford A Dissection

in the resection of the aortic arch with a standford A aortic dissection what surgical intervention is required

A

surgery requires cardiopulmonary bypass, profound hypothermia, and a period of circulatory arrest

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16
Q

Standford A Dissection

with current techniques for aortic arch resection, a period of circulatory arrest of _ - __ minutes at a body temp of ___- ____ C can be tolerated

A

with current techniques for aortic arch resection, a period of circulatory arrest of 30-40 minutes at a body temp of 15-18C can be tolerated

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17
Q

Standford A

what is the major complication of aortic arch replacement

A

neuro deficits
occurs in 3-18% of patients,

appears that selective antegrade cerebal perfusion decreases but does not completely eliminate the mobidity and mortality associated with the procedure

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18
Q

Standford B/Debakey 3

patietns with an acute, but uncomplicated type B aortic dissection with normal hemodynamics, no periaortic hematoma, or branch vessel involvement can be treated with

A

medical therapy

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19
Q

Standford B DIssection/DeBakey 3

medical therapy consists of

A

intraarterial monitoring of SBP and UOP
drugs to control BP and the force of LV contraction
BB, Cardene, Sodium NItroprusside

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20
Q

surgery is indicated for patients with type B aortic dissection who have signs of

A

impending rupture (persistent pain, hyoptension, L-sided hemotrhorax); ischemia of legs, abdominal viscera, spinal cord and/or renal failure

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21
Q

risk factors for aortic dissection

A

HTN, atherosclerosis, aneurysm, family hx, cocaine use, and inflammatory disease

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22
Q

inherited diseases at risk for aortic dissection

A

marfans, ehlers Danlos, bicuspid aortic valve, non-syndrome family hx

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23
Q

cause of aortic dissection

A

blunt trauma, cocaine, iatrogenic (medical treatment)
* cardiac catherization, aortic manipulation, cross clamping, arterial incision

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24
Q

when is dissection most common

A

men and pregnant women in 3rd trimester

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25
aortic aneursym rupture triad of symptoms
hypotension back pain pulsatile abdominal mass
26
where do most abdominal aortic aneursysms rupture
left retroperitoneum
27
how can exsanguination be prevented in aortic aneursym rupture
clotting and the tamponade effect in the retroperitoneum accumulation of blood
28
why might euvolemic resusictiation be deferred until the rupture is surgically controlled
resulting increase in BP without control of bleeding may lead to loss of retroperitoneal tamponade and further bleeding -> hypotension -> death
29
suspected Standford A- abdominal aortic aneursysm POC
immediate operation without preoperative testing or volume resuscitation
30
4 causes of mortality realted to surgeries of thoracic aorta
MI repsiratory failure renal failure stroke | assess ECHO, presence of CAD, valve dysfunction
31
what preoperative evaluation findings might preclude a pt from an elective AAA resection
severe reduction in FV1 or renal failure
32
smoking/COPD are predictors of post-aortic surgery...
respiratory failure PFTs and ABGs help define risk | consider preop bronchodilators, ABX, chest physiotherapy
33
preop renal dysfuncftion is the most important indicator of post aortic surgery renal failure what are some considerations to prevent worsening renal function
preop hydration avoid hypovolemia, hypotension, low cardiac output avoid nephrotoxic drugs | avoid intraop AKI
34
h/o of stroke or TIA preop considerations
carotid ultrasound angiogram of brachiocephalic and intracranial arteries
35
severe carotid stenosis shold have what before elective surgery of an aneurysm
recommended CEA
36
Anterior spinal artery syndrome
caused by lack of blood flow to the anterior spinal artery | anterior spinal artery responsible for perfusing anterior 2/3 of cord
37
ischemia from anterior spinal artery syndrome can lead to
loss of motor function below infarct diminished pain and temperature sensation below the infarct autonomic dysfuncion leading to hypotension and loss of bowel and bladder
38
why is the anterior spinal artery the most common spinal cord ischemia problem
minimal collateral perfusion | posterior spinal cord has 2 posterior arteries allowing for collateral
39
common causes of anterior spinal artery syndrome
aortic aneursyms, aortic dissection, atherosclerosis, trauma
40
CVA division between ischemic and hemorrhagic percentages
ischemic - 87% hemorrhagic - 13% | sudden onset of neuro deficit
41
what is a big predictor of CVA
carotid disease
42
leading cause of disability in the US
CVA | 3rd leading cause of death in US
43
what is a TIA
subset of self-limited ischemic stroke symptoms resolve in 24hr | TIA's have 10x greater risk of subsequent stroke
44
risk for cerebral vascular accidents
inherited - age, Hx of stroke, family Hx, male, black race, sickle cell modifiable- smoking, HTN, DM, CAD, Afib, HF, HLD,obesity
45
carotid disease diagnositic testing
angiography - dx vascular obstruction CT/MRI - ID aneurysms and AVM Transcranial doppler US - indirect evidence of vacular occlusions Carotid Auscultation - ID bruits Carotid US - quantify degree of stenosis ## Footnote ID - identify
46
where does carotid stenosis commonly occur
at internal/external carotid bifurcation due to turbulent blood flow at the branch point ## Footnote workup includes eval for sources of emboli (Afib, HF, valvular vegetation, or paradoxical emboli in the setting of PFO)
47
when is TPA recommended for CVA
within 4.5 hour if they meet criteria
48
interventional radiology treatment for CVA
intra-arterial thrombolysis intravascular thrombectomy *benefits seen up to 8hr after onset of CVA | remvoes clots under fluroscopy
49
When is a CEA indicated for patients
surgical treatment for severe carotid stenosis (lumen diameter 1.5 mm or >70% blockage ## Footnote **key point slide**
50
what is carotid stenting and risks asscociated with it
alternetive to CEA major risk of microembolization -> CVA embolic protection devices to mitigate risks
51
medical treatment for CVA
antiplatelet therapy smoking cessation BP control cholesterol control Diet and exercise | minimize risks!
52
CEA preop eval
neuro eval - establish preop deficts CV disease - CAD is prevalent in carotid disease (MI major perioperative M&M) HTN - optimize & look at trend CPP= MAP - ICP **maintain collateral flow through stenotic vessels especially with cross-clamping** extreme head rotation/ flexion/extension may compres contralateral artery flow :( cerebral oximetry devices to determine cerebral perfusion
53
your patient has severe carotid disease and severe CAD... how can you optimize this patietnt for a CEA
stage cardiac revascularization and CEA **most compromised area takes priority**
54
# StO2 is effected by 1. cerebral oxygenation whcih is effected by 2. and cerebral O2 consumption (CRMO2) which is effected by
1. MAP, Cardiac Output, SaO2/SpO2, Hgb, PaCO2 2. temperature and depth of anesthesia
55
what is the definition of peripheral artery disease
ankle-branchial index (ABI) < 0.9 | ABI = Ratio of SBP @ ankle : SBP @ brachial artery
56
chronic hypo-perfusion is typically due to
athersosclerosis | may be also due to vasculitis
57
acute occlusions to are typically due to
embolism
58
incidence of PVD increases with age
exceeding 70% by age 75
59
atherosclerosis is systemic and patients with PAD have
3-5x increased risk of MI and CVA
60
risk factors for PAD
advanced age family history smoking DM HTN obesity increased cholesterol
61
signs and symptoms of PAD
intermittent claudication resting extremity pain decreased pulses SQ atrophy hair loss coolness cyanosis *relief with hanging LE overside of bed bc it increases hydrostatic pressures
62
PAD diagnosis (4)
**doppler US:** provides a pulse volume waveform identifies arterial stenosis **duplex US:** can identify areas of plaque formation & claudification **transcutaneuos oximetry:** can assess the severity of tissue ischemia **MRI with contrast angiography:**used to guide endovascular intervention or surgical bypass
63
PAD medical treatmentt
exercise BP control cholesterol control glucose control
64
medical/surgical intervention for PAD
revascularization indicated with disabling claduication or ischemia surgical reconstruction - arterial bypass procedure endovascular repair - transluminal angioplasty or stent placement
65
acute artery occlusion frequently due to _____ _______
frequently due to **cardiogenic embolism**
66
common causes of acute artery occlusion (2)
left atrial thrombus arising from Afib Left ventricular thrombus arising from dilated cardiomyopathy after MI ## Footnote Less common - valvular heart disease, endocarditis, PFO, atheroemboli, plaque rupture, hypercoagulability, trauma
67
s/s of acute artery occlusion
limb ischemia, pain/parasthesia, weakness, decreased peripheral pulses, cool skin, color changes distal to occlusion
68
Diagnosis and treatment of acute artery occlusion
diagnosis: arteriography treatment: surgiacl embolectomy, anticoagulation, amputation (last resort)
69
what is subclavian steal syndrome? what is the treatment?
occluded SCA proximal to vetebral artery causing veterbral artery blood flow to be diverted away from brainstem | treatment: SC endarterectomy is curative
70
risk factors for subclavian steal syndomre
atherosclerosis, Takayasu Arteritis, aortic surgery
71
raynaud's phenomenon
episodic vasospastic ischemia of the digits effects women> men
72
Primary and secondary causes of raynauds
rheumatic disease drugs/toxins - BB, cocaine, tobacco endocrine disease trauma arterial disease hemothologic disorders neoplasma - ovarian cancer ## Footnote May also appreat with CREST syndrome (scleroderma subtype)
73
symptoms diagnosis treatment of raynauds
digital blanching or cyanosis with cold exposure or SNS activation dx: based on H&P treatment: protection from cold, CCB, alpha- blockers, surgical sympathectomy for severe ischemia
74
common peripheral venous diseases processes that occur during surgery (3)
superficial thombophelbitis deep vein thrombosis chronic venous insuffiency | **DVT may lead to PE and leading cause of periop M&M**
75
virchows triad that predispose to venous thrombosis
1. venous stasis 2. hypercoagulability 3. disrupted vascualr endothelium
76
risk factors for thromboembolism
77
what surgery results in a superficial thrombophelbitis and DVT in surgey
50% total hip replacements *normally subclinical and completely resolve
78
DVT is associated with extremity pain and swelling what are the risk factors
age > 40 surgery > 1hr in duration cancer ortho surgery on pelvis and low extremities abdomnial surgery
79
doppler US is senstive in detecting proximal or distal thrombosis
proximal | venography and impedance plethysmograpgy are also useful
80
prophylatic measures for DVT
SCDs, SQ heparin 2-3x/day, regional anesthesia to promote early ambulation
81
DVT treatment
anticoagulation: warfarin + Heparin or LMWH PO anticoags for 6 moinths or longer IVC filter for recurrent PE or CI to anticoags | Heparin is DC'd when Warfarin achieves therapeutic effect (INR 2-3)
82
systemic vasculitis
Diverse group of vascular inflammatory diseases with characteristics that are often grouped by the size of the vessels at the primary site of the abnormality ## Footnote Additionally, vasculitis can be a feature of connective tissue diseases such as systemic lupus erythematosus and rheumatoid arthritis
83
Large-artery vasculitis includes:
Takayasu arteritis  Temporal (or giant cell) arteritis
84
Medium-artery vasculitis includes:
Kawasaki disease, which is most prominently the coronary arteries
85
Medium to small-artery vasculitis includes:
thromboangiitis obliterans Wegener granulomatosis polyarteritis nodosa
86
temporal (giant cell) arteritis
inflammation of the arteries of the head and neck symptoms: unilateral headache, scalp tenderness, jaw claudication ## Footnote Opthalmic Arterial branches may lead to ischemic optic neuritis and unilateral blindness
87
treatment and diagnosis of temporal (giant cell) arteritis
Tx: Prompt initiation of **corticosteroids** indicated for visual symptoms, to prevent blindness Dx: Biopsy of temporal artery shows arteritis in 90% of pts
88
Thromboangiitis Obliterans “Buerger Disease”
Inflammatory vasculitis leading to small & medium vessel occlusions in the extremities Autoimmune response triggered by nicotine | Tobacco use is most predisposing factor
89
5 diagnostic criteria for Thromboangiitis Obliterans “Buerger Disease”
h/o smoking onset before age 50 infrapopliteal arterial occlusive dz upper limb involvement Absence of risks factors for atherosclerosis (outside of tobacco) | Diagnosis confirmed w/biopsy of vascular lesions
90
Symptoms of Thromboangiitis Obliterans “Buerger Disease” (4)
* forearm, calf, foot claudication * Ischemia of hands & feet * Ulceration and skin necrosis * Raynaud's is commonly seen
91
Thromboangiitis Obliterans “Buerger Disease” treatment (3)
Smoking cessation-most effective tx Surgical revascularization No effective pharmacological tx
92
Anesthesia implications for Thromboangiitis Obliterans “Buerger Disease”
Meticulous positioning/padding due to poor perfusion Avoid cold; Warm the room and use warming devices Prefer non-invasive BP and conservative line placement
93
Polyarteritis Nodosa is an antineutrophyl cytoplasmic antibody (ANCA) negative vasculitis associated with _____ and involves what type of arteries what does the inflammation lead too
w/ Hep B, Hep C, or Hairy Cell Leukemia **Small & medium arteries involved** Inflammation results in glomerulonephritis, myocardial ischemia, peripheral neuropathy and seizures HTN generally caused by renal dz Renal failure is primary cause of death
94
treatment for Polyarteritis Nodosa and anesthesia implications
Tx: steroids, cyclophosphamide, treating underlying cause (s/a cancer) Anesthesia Implications: consider coexisting renal and cardiac disease, HTN Steroids likely beneficial
95
what causes Lower Extremity Chronic Venous
**Long standing venous reflux & dilation** Effects 50% of the population Ranges mild-severe Mild sx: telangiectasias, varicose veins Severe sx: edema, skin changes, ulceration
96
Risk factors for Lower Extremity Chronic Venous Disease
advanced age family hx pregnancy ligamentous laicity previous venous thrombosis LE injuries prolonged standing obesity smoking sedentary lifestyle high estrogen levels
97
diagnositc criteria Lower Extremity Chronic Venous Disease
Sx of leg pain, heaviness, fatigue Confirmed by ultrasound showing venous reflux **Retrograde blood flow > 0.5 seconds**
98
the initial conservative treatment for lower extremity chronic venous insufficiency
Leg elevation Exercise Weight loss Compression therapy Skin barriers/emollients Steroids Wound management
99
conservative medical management for lower extremity chronic venous disease
Diuretics Aspirin Antibiotics Prostacyclin analogues Zinc sulphate | *If management fails, ablation may be performed
100
ablation for chronic venous disease methods, indications, contraindications
101
ascending dissection
catastrophic, requires emergent surgical intervention Standfor A, Debakey 1/2 mortality increases 1-2% per hour overall mortality 27-58%
102
overview of treatment for aortic dissection
Standford A - emergent surgery Standford B - rarely treated with urgent surgert *uncomplicated type B = BP control BB, Aline impending rupture = surgical treatment
103
subclavian steal syndrome symptoms
syncope, vertigo, ataxia, hemiplegia, ipsilateral arm ischemia *effected arm SBP may be ~20 mmHg lower *Bruit over SCA
104
surgical intervention for low extremity chronic venous disease
usually last resort

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