Vascular Flashcards
(150 cards)
1
Q
What is the triad of aortic aneurysm rupture?
A
Hypotension
Back pack
Pulsatile Abdominal Mass
2
Q
Where do most aortic abdominal aneurysms rupture?
A
Left retroperitoneum
3
Q
Though hypovolemic shock can be present, how can exsanguination in aortic aneurysm rupture?
A
clotting and the tamponade effect in the retroperitoneum
4
Q
Why would you defer euvolemic resuscitation until the rupture is controlled?
A
because it can result in an increase in BP without control of bleeding which may lead to loss of retroperitoneal tamponade leading to further HYPOTENSION, bleeding, and death
5
Q
Unstable Aortic Aneursym require immediate..
A
operation without preop testing or volume resuscitation
6
Q
What are the 4 primary causes of mortality related to surgeries of thoracic aorta
A
MI
Resp failure
Renal Failure
Stroke
7
Q
Aortic Aneurysm Resection Preop
_____ may require intervention prior to surgery
A
Ischemic heart disease
Cardiac eval test: stress test, echo, radionuclide imaging
8
Q
What may preclude (prevent) a patient from having AAA resection?
A
SEVERE reduction in FEV1 or renal failure
9
Q
What are predictors of post aortic surgery respiratory failure ?
A
Smoking
COPD
Use PFT and ABG to define risk
**consider brochodilators, ABX, or chest physiotherapy
10
Q
AAA rupture
Preop renal dysfunction is the most important indicator of post-aortic surgery renal failure
Make sure to
A
PreOp hydration
Avoid hypovolemia, Hypotension, low cardiac output
No nephrotoxic drugs
11
Q
Preop Eval for AAA
what if they had a history of stroke or TIA
Obtain a-___
A
carotid ultrasound
Angiogram of brachiocephalic and intracranial arteries
12
Q
Preop Eval AAA
What if they have severe cartodi stenosis?
A
recommend work up for CEA
Carotid endarterectomy
13
Q
Anterior Spinal Artery Syndrome Patho
A
lack of blood flow to the anterior spinal artery
anterior spinal artery responsible perfusing 2/3 of spinal cord
14
Q
What does ischemia to the anterior spinal artery lead to
A
loss of motor function below the infarct
diminished pain and temp sensation below the infarct
autonomic dysfunction
leading to hypotension and loss of bowel and bladder
15
Q
why is anterior spinal artery syndrome the most common form of spinal ischemia?
A
because the anterior spinal artery has minimal collateral perfusion thus its very vulnerable
- The posterior spinal cord has 2 spinal arteries
16
Q
Common causes for ASA syndrome
A
Aortic aneurysm, aortic dissection, atherosclerosis, trauma
17
Q
CVA percentage
A
87 ischemic
13 hemorrhagic
**sudden osent of neuro defecits
18
Q
What is the prominent predictor of CVA
A
Carotid disease
19
Q
CVA is the 1st leading ___
A
cause of disability in US
3rd leading cause of death
20
Q
What is a TIA?
A
subset of self limited ischemic strokes
21
Q
How long do TIAs take to resolve
A
24 hours
22
Q
Carotid Diagnostic Test
A
Angiography to diagnose vascular occlusion
23
Q
TIAS have a ____greater rx of subsequent strokes
A
10
24
Q
What can identify both carotid disease and aneurysms, and AMV
A
CT and MRI
25
Cartoid Dx
What diagnostic may give you indirect evidence of vascular occulusions with rela time bedside monitoring?
transcranial doppler US
26
Carotid DZ
Diagnostic to identify bruits?
Carotid Auscultation
27
Cartoid DZ
Carotid Ultrasound can idenitfy___
degree of carotid stenosis
28
Where does cartoid stenosis usually occur?
at the internal and external carotid birufication due to turbulent blood flow at the branch point
29
Carotid DZ
Work Up Includes
evaluation for sources of emboli s/a Afib, heart failure, valvular vegetation, or paradoxical emboli in the setting of PFO (patent foramen ovale)
30
Treatment for CVA
TPA within 4.5 hours
Interventional radiology
-Intraarterial thrombolysis
-Intravascular thrombectomy
Carotid Endartectomy ( CEA)
Carotid Stenting
alternative to CEA
31
when can you see the benefits of a CVA after an intravascular thrombectomy
8 hours
32
(measurements)When is CEA indicated
LUMEN diameter 1.5 mm or greater than 70 percent blockage
33
Whats the major risk to carotid stenting
MICROEMBOLI - CVA
34
Ongoing Medical Treatment of CVA
Antiplatelet
Smoking cessation
BP control
cholesterol
Diet and physical activity
35
CEA Preop
Neuro eval - for defecits
htn COMMON * estabilish acceptable BP to optimize CPP ( MAP - ICP_
36
What is CV dz prevelant with carotid stenosis
CAD
37
What is a major cause of perioperative mortality and mobidity in CEA
MI
38
CEA during surgery
Maintain collateral blood flow through stenotic vessel
**Extreme head rotation/flexion/extension may compress contralateral artery flow
***Cerebral Oximetry Devices
39
Clinical Dilemma: Severe Carotid Disease + Severe CAD
Must stage cardiac revascularization and CEA
**most compirsed area should take priority
40
Cerebral 02 consumption effected by:
Temperature
Anesthesia
41
Cerebral Oxygenation effected by:
MAP
COP
Sa02
HGB
PaC02
42
Peripheral Artery Disease
Results in compromised blood flow to the extremities
43
Peripheral Artery Disease is defined by an ankle- brachial index of
ABI less than 0.9
44
ABI is a ratio of SBP at tthe
ankle to the brachial artery
45
PAD
Chronic hypo-perfusion is typically due
atherosclerosis
may be due to vasculities
WHILE ACUTE occlusions are due to emboli
46
Incidence of PAD increase with
age exceeding by 70 percent by age 75
47
Patients with PAD have 3-5 increased risk of
MI and CVA
48
S/S PAD
intermittent claudication
Resting extremity pain
Decreased pulses
Subcutaneous atrophy
Hair loss
Coolness
Cyanosis
* Relief with hanging LE extremity over bed
49
PAD risk factors
Advanced Age
Family hx
Smoking
DM
HTN
Obesity
Cholesterol increase
50
What do people with PAD have relief with hanging their lower extremities over the side of their bed
due to increased hydrostatic pressure
51
PAD Diagnosis
Doppler US - provide pulse waveform to identify arterial stenosis
Duplex US--> plaque formation and calcification
Trancutaneus Oximetry - assess ischemia
MRI with contrast angiography - to guide endovascular intervention or surgical bypass
52
PAD medical treatment
Exercise
Bp control
Cholesterol control
Glucose control
53
PAD medical intervention
Revascularization indicated w/ disabiling claudication or ischemia
Surgical reconstruction - arterial bypass procedure
Endovascular repair - transluminal angioplasty or stent placement
54
Acute Artery Occulsion is frequently due to
cardiogenic emboli
55
Common causes of Acute Artery Occlusion
Left artial thrombus arising from Afib
Left ventricular thrombus from dilated cardiomyopathy after MI
56
Acute Artery Occlusion Less common causes
valvular heart dz, endocardidits , PFO
Noncardiac: atheroemboli, plaque rupture, hypercoagulability, trauma
57
S.S of acute artery occlusion/acute limb ischemia
Limb ischemia, pain/parethesia, weakness, decrease peripheral pulses, cool skin, color changes distal to occulusion
58
Acute Artery Oclussion Diagnosis
Arteriography
59
Treatment for Acute Artery Occlusion
surgical embolectomy, anticoagulation, amputation ( last resort)
60
Subclavian Steal Syndrome
SCA ( superior cerebellar artery) proximal to vertebral artery
-- causing vertebral artery blood flow to be diverted away from brainstem
61
Subclavian Steal Syndrome ss
Syncope
Vertigo
Ataxia
Hemiplegia
**ipsilateral arm ischemia
**effected arm SBP may be 20 mmhg lower
Bruit over SCA *superior cerebellary artery
62
Risk Factors for Subclavian Steal Syndrome
Atheroscelorisis
Takayasu Arteritis
aortic surgery
63
Subclavian Steal Syndrome Rx
SC endarterectomy is curative
64
Raynaud's Phenomenom
Episodic vasospastic ischemia of the digits
effects more woman
65
Raynauds S/S
CREST syndrome
digital blanching or cyanosis with cold exposure or SNS activation
66
Raynauds Phenomenom treatment
protection from cold
CBB
Alpha channel bloclers
**surgical sympathectomy for severe ischemia
67
Peripheral Venous Disease
What are the most common PVD process that occur during surgery?
superficial thrombophelibitis
deep vein thrombosis
chronic venous insufficiency
68
Why is DVT a major concern
can lead to PE leading to increase MM
68
What is Virshows Triad as it relates to Peripheral Venous Disease
hypercoagulability
venous stasis
*disrupted vascular endothelium
69
Risk factors for thromboembolism
pregnancy
low cardiac output - chf
varicose veins
estrogen - oral contraceptives
Obesity
Inflammatory disease
70
Superficial Thrombophlebitis & DVT is highest in what type of surgeries?
appox 50% total hip replacements
71
DVT diagnostics
doppler U/S more sensitive for detecting PROXIMAL thrombosis over distal thrombosis
Venography and impedance plethysmography also useful
72
DVT associated with these risk factors
↑risk factors: >age 40, surgery >1h, cancer, ortho surgeries on pelvis & LEs, abdominal surgery
73
Prophylaxis for --> Superficial Thrombophlebitis & DVT
SCDs
SBQ heparin 2-3 days
74
What type of anesthesia can decrease risk of superficial thrombophlebitits and DVT
Regional anesthesia can greatly ↓risk d/t earlier postop ambulation
75
Risk and Predisposing Factors For Development of DVT
age greater than 40
knee or hip replacement ( high risk)
stroke
pregnancy ( low and med risk)
76
Mod Risk Steps to Prevent DVT
subq heparin
iv dextran
compression
77
High Risk DVT ways to prevent
compression
subq heparin
**warfarin
iv dextran or VENA CAVA FILTER
78
Repeat on day _ and _
compression ultrasound of proximal veins or impedence plethysmography
2 and 7
79
DVT treatments Anticoags
Warfarin + Heparin
or
LMWH
80
DVT treatmemnt
LMWH advantages over unfractionated heparin
longer half life(?) and more predicatable dose response
Doesnt require serial assessment of APPT
Less bleeding
81
DVT treatment
LMWH disadvantages
higher cost
lack of reversal agent
82
DVT Treatment
Warfarin (vit K antagonist) is initiated during heparin treatment and adjusted to achieve INR btw ____
2-3
83
DVT treatment
When is heparin discontinued
in terms with warfarin
heparin discontined when warfarin achieves therapeutic effect
84
DVT treatment
PO anticoagulants continued _____
6 months or longer
85
_____ may be placed in pts w/ recurrent PE, or have contraindication to anticoagulants
IVC Filter
86
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
87
Large-artery vasculitis
Takayasu arteritis
Temporal (or giant cell) arteritis
88
Medium-artery vasculitis includes:
Kawasaki disease, which is most prominently the coronary arteries
89
Medium to small-artery vasculitis includes:
thromboangiitis obliterans
Wegener granulomatosis
polyarteritis nodosa
90
Systemic Vasculities
Additionally, vasculitis can be a feature of connective tissue diseases such as
systemic lupus erythematosus and rheumatoid arthritis
91
Temporal (Giant Cell) Arteritis
Is what?
Inflammation of arteries of the head and neck
92
Temporal (Giant Cell) Arteritis
S/S
unilateral, headache, scalp tenderness, jaw claudication
93
Temporal (Giant Cell) Arteritis
Opthalmic Arterial branches may lead to ___________
ischemic optic neuritis and unilateral blindness
94
Temporal (Giant Cell) Arteritis Treatment
Prompt initiation of corticosteroids indicated for visual symptoms, to prevent blindness
95
Temporal Giant Cell Arterities
Diagnostics
Biopsy of temporal artery shows arteritis in 90% of pts
96
Aortic aneurysm: Dilation of all ___ layers of artery, leading to a >___increase in diameter
3
50 percent
97
When is surgery indicated for aortic aneursym
Surgery indicated @ >5.5 cm diameter
Aortic aneurysm rupture is associated with a 75% mortality rate
98
2 Types -Aortic Aneurysm
2 types:
Fusiform: Uniform dilation along entire circumference of arterial wall
Saccular: berry-shaped bulge to one side
99
Whats the fastest way to diagnose a suspected dissection
*In suspected dissection, doppler echocardiogram is fastest/safest measure of obtaining a diagnosis of aneurysm
100
Thromboangiitis Obliterans “Buerger Disease”
Patho
Inflammatory vasculitis leading to small & medium vessel occlusions in the extremities
101
What triggers Thromboangiitis Obliterans " Buerger Disease"
autoimmune response trigged by nicotine
TOBACCO USE is the most predisposing factor
102
Buerguer Disease more often in what gender
males less than 45
103
5 diagnostic criteria for Thromboangiitis Obliterans
1. history of smoking
2.onset before 50
3.infrapopliteal arterial occlusive
4.upper lumb involvement
5.absense of risk factors for atherosclerosis *outside of tobacco
104
Buerger Disease Diagnosis is confirmed with
Biopsy of vascular lesions
105
Thromboangiitis Obliterans “Buerger Disease” SS
forearm, calf, foot claudication
Ischemia of hands and feet
ulceration and skin necrosis
Raynaud's is commonly seen
106
Thromboangiitis Obliterans “Buerger Disease” Treatment
Smoking Cessation ** is most effective
Surgical revascularization
No effective pharmacologic tx
107
Anesthesia implications for Thromboangiitis "Beurger Disease"
Meticulous Positioning/Padding
Avoid cold; warm the room and use warming devices
**PREFER NON invasive BP versus conservative line placement
108
Polyarteritis Nodosa patho
Antineutrophyl cytoplasmic antibody (ANCA) negative vasculitis
Small & medium arteries involved
109
Polyarteritis Nodosa is associated with
Hep B, Hep C, or hairy cell leukemia
110
Polyarteritis Nodosa
Inflammation results in
glomerulonephritis, myocardial ischemia, peripheral neuropathy and seizures
111
What is the primary cause of death for polyarteritis nodosa?
renal failure
**htn in this disease is generally caused by this disease
112
Polyarteritis Nodosa RX
Tx: steroids, cyclophosphamide, treating underlying cause (s/a cancer)
113
Polyarteritis Nodosa Anesthesia Complications
Consider coexisting renal dz,cardiac dz and htn
**STEROIDS BENEFICIAL
114
Lower Extremity Chronic Venous Disease is due to
Long standing venous reflux & dilation
Effects 50% of the population
115
Lower Extremity Chronic Venous Diseasess
Ranges mild-severe
Mild sx: telangiectasias, varicose veins
Severe sx: edema, skin changes, ulceration
116
Lower Extremity Chronic Venous Disease Risk Factors
advanced age
family hx
pregnancy
ligamentous laicity
previous venous thrombosis
LE injuries
prolonged standing
obesity
smoking
sedentary lifestyle
high estrogen levels
117
Lower Extremity Chronic Venous Insufficiency Diagnosis
Diagnostic criteria: Sx of leg pain, heaviness, fatigue
Confirmed by ultrasound showing venous reflux
Retrograde blood flow > 0.5 seconds
118
Lower Extremity Chronic Venous Insufficiency treatment
Treatment: initially conservative
Leg elevation
Exercise
Weight loss
Compression therapy
Skin barriers/emollients
Steroids
Wound management
119
Lower Extremity Chronic Venous DiseaseConservative medical management:
Conservative medical management:
Diuretics
Aspirin
Antibiotics
Prostacyclin analogues
Zinc sulphate
*If management fails, ablation may be performed
120
Ablation for Chronic Venous Dz
Indications
Venous hemorrhage
Thrombophlebitis
Symptomatic venous reflux
121
methods chronic venous insufficiency
Thermal ablation w/laser
Radiofrequency ablation
Endovenous laser ablation
Sclerotherapy
122
Contraindications for Ablation for Chronic Venous
Pregnancy
Thrombosis
PAD
Limited mobility
Congenital venous abnormalities
123
Lower Extremity Chronic Venous
Surgical Intervention
Procedures
Saphenous vein inversion
High saphenous ligation
Ambulatory Phlebectomy
Transilluminated-powered phlebectomy
Venous ligation
Perforator ligation
124
___________are the leading cause of perioperative morbidity and mortality in patients undergoing noncardiac surgery
Cardiac complications
The incidence of these complications is higher in patients undergoing vascular surgery
125
_______ is a systemic disease. Pts with peripheral arterial dz have a 3-5 times greater risk of cardiovascular ischemic events
Atherosclerosis
126
Data from ______________ and _________ studies suggest that carotid artery stenosis with a residual luminal diameter of 1.5 mm (70–75% stenosis) represents significant stenosis. If collateral cerebral blood flow is not adequate, TIAs and ischemic infarction can occur
transcranial doppler and carotid duplex ultrasound
127
_____________ may be observed frequently during and after carotid endarterectomy
* Both hypertension and hypotension
128
__________ is typically caused by cardiogenic embolism. Emboli may arise from a thrombus in the left ventricle that develops because of MI or dilated cardiomyopathy
Acute arterial occlusion
129
Other cardiac causes of systemic emboli are _________
valvular heart disease, prosthetic heart valves, infective endocarditis, left atrial myxoma, Afib, and atheroemboli
130
* __________is an inflammatory vasculitis leading to occlusion of small and medium-sized arteries and veins in the extremities
Thromboangiitis obliterans
131
Pts at low risk for DVT require minimal prophylactic measures such as
early postop ambulation and compression stockings
132
The risk of DVT may be much ______ in patients >40 y/o who are undergoing surgery >1 hour, especially LE orthopedic, pelvic or abdominal surgery, and surgeries that require a prolonged bed rest or limited mobility
higher
133
Endovascular repair of aortic lesions is a relatively new technique with significant improvements in perioperative mortality
t/f
134
Aortic Dissection patho
Dissection: Tear in intimal layer of the vessel, causing blood to enter the medial layer
135
__________procedures have emerged as alternative, less invasive methods of arterial repair
Endovascular arterial
136
Ascending dissection: Catastrophic, requires emergent surgical intervention
Stanford A, Debakey 1 & 2
Mortality increases by 1-2% per hr
Overall mortality 27-58%
137
Aortic Dissection S/S
Sx: Severe sharp pain in posterior chest or back
138
Aortic Dissection
Stable Versus Unstable Diagnosis
Diagnosis:
Stable= CT, CXR, MRI, Angiogram
Unstable=Echocardiogram
139
Stanford A Dissection
Ascending aorta: All patients with acute dissection involving the ascending aorta should be considered candidates for surgery
The most commonly performed procedures:
ascending aorta & aortic valve replacement w/a composite graft
replacement of the ascending aorta and resuspension of the aortic valve
140
Stanford A Dissection
Aortic Arch: in patients with acute aortic arch dissection, resection of the aortic arch is indicated. Surgery requires cardiopulmonary bypass, profound hypothermia, and a period of circulatory arrest
With current techniques, a period of circulatory arrest of 30-40 minutes at a body temperature of 15-18°C can be tolerated by most patients
Neurologic deficits are the major complications associated with replacement of the aortic arch
These occur in 3-18% of pts, and it appears that selective antegrade cerebral perfusion decreases but does not completely eliminate the morbidity and mortality associated with this procedure.
141
Stanford B Dissection
Descending thoracic Aorta: Pts with an acute, but uncomplicated type B aortic dissection who have normal hemodynamics, no periaortic hematoma, and no branch vessel involvement can be treated with medical therapy
Medical therapy consists of:
1) intraarterial monitoring of SBP and UOP
2) drugs to control BP and the force of LV contraction (BBs, Cardene, SNP)
This patient population has an in-hospital mortality rate of 10%
The long-term survival rate with medical therapy only is 60-80% at 5 years and 40-50% at 10 years
Surgery is indicated for patients with type B aortic dissection who have signs of impending rupture (persistent pain, hypotension, left-sided hemothorax); ischemia of the legs, abdominal viscera, spinal cord, and/or renal failure
Surgical treatment of distal aortic dissection is associated with a 29% in-hospital mortality rate
142
_____ arch dissections- emergent surgery
Ascending
143
Descending arch dissections- rarely treated with urgent surgery
Uncomplicated type B → often admitted for BP control (SA BBs preferred, Aline)
144
Impending rupture of type b dissection
Sx of impending rupture (posterior pain, HoTN, hemothorax)→surgical tx
145
Aortic Dissection Risk Factore
Risk Factors: HTN, atherosclerosis, aneurysms, fam hx, cocaine use, & inflammatory diseases
146
Aortic Dissection Inherited Disorders
Marfans, Ehlers Danlos, Bicuspid Aortic Valve, non-syndrome familial hx
147
Causes of Dissection
Causes of dissection: blunt trauma, cocaine, iatrogenic (c/b medical treatment)
148
Dissection - Iatrogenic causes
Iatrogenic causes related to: cardiac catheterization, aortic manipulation, cross-clamping & arterial incision
149
Dissection is more common in
in men and pregnant women in 3rd trimester
