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
Q

aortic aneursym rupture triad of symptoms

A

hypotension
back pain
pulsatile abdominal mass

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26
Q

where do most abdominal aortic aneursysms rupture

A

left retroperitoneum

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27
Q

how can exsanguination be prevented in aortic aneursym rupture

A

clotting and the tamponade effect in the retroperitoneum accumulation of blood

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28
Q

why might euvolemic resusictiation be deferred until the rupture is surgically controlled

A

resulting increase in BP without control of bleeding may lead to loss of retroperitoneal tamponade and further bleeding -> hypotension -> death

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29
Q

suspected Standford A- abdominal aortic aneursysm POC

A

immediate operation without preoperative testing or volume resuscitation

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30
Q

4 causes of mortality realted to surgeries of thoracic aorta

A

MI
repsiratory failure
renal failure
stroke

assess ECHO, presence of CAD, valve dysfunction

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31
Q

what preoperative evaluation findings might preclude a pt from an elective AAA resection

A

severe reduction in FV1 or renal failure

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32
Q

smoking/COPD are predictors of post-aortic surgery…

A

respiratory failure
PFTs and ABGs help define risk

consider preop bronchodilators, ABX, chest physiotherapy

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33
Q

preop renal dysfuncftion is the most important indicator of post aortic surgery renal failure what are some considerations to prevent worsening renal function

A

preop hydration
avoid hypovolemia, hypotension, low cardiac output
avoid nephrotoxic drugs

avoid intraop AKI

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34
Q

h/o of stroke or TIA preop considerations

A

carotid ultrasound
angiogram of brachiocephalic and intracranial arteries

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35
Q

severe carotid stenosis shold have what before elective surgery of an aneurysm

A

recommended CEA

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36
Q

Anterior spinal artery syndrome

A

caused by lack of blood flow to the anterior spinal artery

anterior spinal artery responsible for perfusing anterior 2/3 of cord

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37
Q

ischemia from anterior spinal artery syndrome can lead to

A

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

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38
Q

why is the anterior spinal artery the most common spinal cord ischemia problem

A

minimal collateral perfusion

posterior spinal cord has 2 posterior arteries allowing for collateral

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39
Q

common causes of anterior spinal artery syndrome

A

aortic aneursyms, aortic dissection, atherosclerosis, trauma

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40
Q

CVA division between ischemic and hemorrhagic percentages

A

ischemic - 87%
hemorrhagic - 13%

sudden onset of neuro deficit

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41
Q

what is a big predictor of CVA

A

carotid disease

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42
Q

leading cause of disability in the US

A

CVA

3rd leading cause of death in US

43
Q

what is a TIA

A

subset of self-limited ischemic stroke
symptoms resolve in 24hr

TIA’s have 10x greater risk of subsequent stroke

44
Q

risk for cerebral vascular accidents

A

inherited - age, Hx of stroke, family Hx, male, black race, sickle cell
modifiable- smoking, HTN, DM, CAD, Afib, HF, HLD,obesity

45
Q

carotid disease diagnositic testing

A

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

ID - identify

46
Q

where does carotid stenosis commonly occur

A

at internal/external carotid bifurcation due to turbulent blood flow at the branch point

workup includes eval for sources of emboli (Afib, HF, valvular vegetation, or paradoxical emboli in the setting of PFO)

47
Q

when is TPA recommended for CVA

A

within 4.5 hour if they meet criteria

48
Q

interventional radiology treatment for CVA

A

intra-arterial thrombolysis
intravascular thrombectomy *benefits seen up to 8hr after onset of CVA

remvoes clots under fluroscopy

49
Q

When is a CEA indicated for patients

A

surgical treatment for severe carotid stenosis (lumen diameter 1.5 mm or >70% blockage

key point slide

50
Q

what is carotid stenting and risks asscociated with it

A

alternetive to CEA
major risk of microembolization -> CVA
embolic protection devices to mitigate risks

51
Q

medical treatment for CVA

A

antiplatelet therapy
smoking cessation
BP control
cholesterol control
Diet and exercise

minimize risks!

52
Q

CEA preop eval

A

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
Q

your patient has severe carotid disease and severe CAD… how can you optimize this patietnt for a CEA

A

stage cardiac revascularization and CEA
most compromised area takes priority

54
Q

StO2 is effected by

  1. cerebral oxygenation whcih is effected by
  2. and cerebral O2 consumption (CRMO2) which is effected by
A
  1. MAP, Cardiac Output, SaO2/SpO2, Hgb, PaCO2
  2. temperature and depth of anesthesia
55
Q

what is the definition of peripheral artery disease

A

ankle-branchial index (ABI) < 0.9

ABI = Ratio of SBP @ ankle : SBP @ brachial artery

56
Q

chronic hypo-perfusion is typically due to

A

athersosclerosis

may be also due to vasculitis

57
Q

acute occlusions to are typically due to

A

embolism

58
Q

incidence of PVD increases with age

A

exceeding 70% by age 75

59
Q

atherosclerosis is systemic and patients with PAD have

A

3-5x increased risk of MI and CVA

60
Q

risk factors for PAD

A

advanced age
family history
smoking
DM
HTN
obesity
increased cholesterol

61
Q

signs and symptoms of PAD

A

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
Q

PAD diagnosis (4)

A

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
Q

PAD medical treatmentt

A

exercise
BP control
cholesterol control
glucose control

64
Q

medical/surgical intervention for PAD

A

revascularization indicated with disabling claduication or ischemia

surgical reconstruction - arterial bypass procedure
endovascular repair - transluminal angioplasty or stent placement

65
Q

acute artery occlusion frequently due to _____ _______

A

frequently due to cardiogenic embolism

66
Q

common causes of acute artery occlusion (2)

A

left atrial thrombus arising from Afib
Left ventricular thrombus arising from dilated cardiomyopathy after MI

Less common - valvular heart disease, endocarditis, PFO, atheroemboli, plaque rupture, hypercoagulability, trauma

67
Q

s/s of acute artery occlusion

A

limb ischemia, pain/parasthesia, weakness, decreased peripheral pulses, cool skin, color changes distal to occlusion

68
Q

Diagnosis and treatment of acute artery occlusion

A

diagnosis: arteriography
treatment: surgiacl embolectomy, anticoagulation, amputation (last resort)

69
Q

what is subclavian steal syndrome?
what is the treatment?

A

occluded SCA proximal to vetebral artery causing veterbral artery blood flow to be diverted away from brainstem

treatment: SC endarterectomy is curative

70
Q

risk factors for subclavian steal syndomre

A

atherosclerosis, Takayasu Arteritis, aortic surgery

71
Q

raynaud’s phenomenon

A

episodic vasospastic ischemia of the digits
effects women> men

72
Q

Primary and secondary causes of raynauds

A

rheumatic disease
drugs/toxins - BB, cocaine, tobacco
endocrine disease
trauma
arterial disease
hemothologic disorders
neoplasma - ovarian cancer

May also appreat with CREST syndrome (scleroderma subtype)

73
Q

symptoms
diagnosis
treatment
of raynauds

A

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
Q

common peripheral venous diseases processes that occur during surgery (3)

A

superficial thombophelbitis
deep vein thrombosis
chronic venous insuffiency

DVT may lead to PE and leading cause of periop M&M

75
Q

virchows triad that predispose to venous thrombosis

A
  1. venous stasis
  2. hypercoagulability
  3. disrupted vascualr endothelium
76
Q

risk factors for thromboembolism

A
77
Q

what surgery results in a superficial thrombophelbitis and DVT in surgey

A

50% total hip replacements
*normally subclinical and completely resolve

78
Q

DVT is associated with extremity pain and swelling
what are the risk factors

A

age > 40
surgery > 1hr in duration
cancer
ortho surgery on pelvis and low extremities
abdomnial surgery

79
Q

doppler US is senstive in detecting proximal or distal thrombosis

A

proximal

venography and impedance plethysmograpgy are also useful

80
Q

prophylatic measures for DVT

A

SCDs, SQ heparin 2-3x/day, regional anesthesia to promote early ambulation

81
Q

DVT treatment

A

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
Q

systemic vasculitis

A

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

Additionally,vasculitis can be a feature of connective tissue diseases such as systemic lupus erythematosus and rheumatoid arthritis

83
Q

Large-artery vasculitis includes:

A

Takayasu arteritis
Temporal (or giant cell) arteritis

84
Q

Medium-artery vasculitis includes:

A

Kawasaki disease, which is most prominently the coronary arteries

85
Q

Medium tosmall-artery vasculitis includes:

A

thromboangiitis obliterans
Wegener granulomatosis
polyarteritis nodosa

86
Q

temporal (giant cell) arteritis

A

inflammation of the arteries of the head and neck
symptoms: unilateral headache, scalp tenderness, jaw claudication

Opthalmic Arterial branches may lead to ischemic optic neuritis and unilateral blindness

87
Q

treatment and diagnosis of temporal (giant cell) arteritis

A

Tx: Prompt initiation of corticosteroids indicated for visual symptoms, to prevent blindness
Dx: Biopsy of temporal artery shows arteritis in 90% of pts

88
Q

Thromboangiitis Obliterans “Buerger Disease”

A

Inflammatory vasculitis leading to small & medium vessel occlusions in the extremities
Autoimmune response triggered by nicotine

Tobacco use is most predisposing factor

89
Q

5 diagnostic criteria for Thromboangiitis Obliterans “Buerger Disease”

A

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
Q

Symptoms of Thromboangiitis Obliterans “Buerger Disease” (4)

A
  • forearm, calf, foot claudication
  • Ischemia of hands & feet
  • Ulceration and skin necrosis
  • Raynaud’s is commonly seen
91
Q

Thromboangiitis Obliterans “Buerger Disease” treatment (3)

A

Smoking cessation-most effective tx
Surgical revascularization
No effective pharmacological tx

92
Q

Anesthesia implications
for Thromboangiitis Obliterans “Buerger Disease”

A

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
Q

Polyarteritis Nodosa is an antineutrophyl cytoplasmic antibody (ANCA) negative vasculitis associated with _____ and involves what type of arteries
what does the inflammation lead too

A

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
Q

treatment for Polyarteritis Nodosa and anesthesia implications

A

Tx: steroids, cyclophosphamide, treating underlying cause (s/a cancer)

Anesthesia Implications: consider coexisting renal and cardiac disease, HTN
Steroids likely beneficial

95
Q

what causes Lower Extremity Chronic Venous

A

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
Q

Risk factors for Lower Extremity Chronic Venous Disease

A

advanced age
family hx
pregnancy
ligamentous laicity
previous venous thrombosis
LE injuries
prolonged standing
obesity
smoking
sedentary lifestyle
high estrogen levels

97
Q

diagnositc criteria Lower Extremity Chronic Venous Disease

A

Sx of leg pain, heaviness, fatigue
Confirmed by ultrasound showing venous reflux
Retrograde blood flow > 0.5 seconds

98
Q

the initial conservative
treatment for lower extremity chronic venous insufficiency

A

Leg elevation
Exercise
Weight loss
Compression therapy
Skin barriers/emollients
Steroids
Wound management

99
Q

conservative medical management for lower extremity chronic venous disease

A

Diuretics
Aspirin
Antibiotics
Prostacyclin analogues
Zinc sulphate

*If management fails, ablation may be performed

100
Q

ablation for chronic venous disease methods, indications, contraindications

A
101
Q

ascending dissection

A

catastrophic, requires emergent surgical intervention
Standfor A, Debakey 1/2
mortality increases 1-2% per hour
overall mortality 27-58%

102
Q

overview of treatment for aortic dissection

A

Standford A - emergent surgery
Standford B - rarely treated with urgent surgert
*uncomplicated type B = BP control BB, Aline
impending rupture = surgical treatment

103
Q

subclavian steal syndrome symptoms

A

syncope, vertigo, ataxia, hemiplegia, ipsilateral arm ischemia
*effected arm SBP may be ~20 mmHg lower
*Bruit over SCA

104
Q

surgical intervention for low extremity chronic venous disease

A

usually last resort