Vascular Disease COPY Flashcards
(195 cards)
1
Q
What are the 3 main arterial pathologies in vascular disease?
A
Aneurysms, dissections, occlusions
2
Q
Which arteries are more likely to be affected by aneurysms and dissections?
A
Aorta & its branches
3
Q
Which arteries are more likely to be affected by occlusions?
A
Peripheral arteries
4
Q
What is an aortic aneurysm characterized by?
A
Dilation of all 3 layers of artery
5
Q
What diameter increase in an artery constitutes an aortic aneurysm?
A
> 50%
6
Q
At what diameter is surgery indicated for aortic aneurysm?
A
> 5.5 cm
7
Q
What is the mortality rate associated with aortic aneurysm rupture?
A
75%
8
Q
What are the 2 types of aortic aneurysms?
A
Fusiform and Saccular
9
Q
How does a fusiform aortic aneurysm appear?
A
Uniform dilation along entire circumference
10
Q
How does a saccular aortic aneurysm appear?
A
Berry-shaped bulge to one side
11
Q
What are some diagnostic tools for aortic aneurysms?
A
CT, MRI, CXR, Angiogram, Echocardiogram
12
Q
Which imaging modality is the fastest/safest in suspected aortic dissection?
A
Doppler echocardiogram
13
Q
What are the treatment options for aortic aneurysms?
A
Medical management, surgery if criteria met
14
Q
What are lifestyle modifications would you implement for aortic aneurysm?
A
- manage BP/cholesterol
- stop smoking
- avoid strenuous exercise/stress
- avoid stimulants
15
Q
When is surgery indicated for aortic aneurysms?
A
> 5.5 cm, growth >10mm/yr, family history of dissection
16
Q
What is the mainstay treatment over open surgery for aortic aneurysms?
A
Endovascular stent repair
17
Q
What is aortic dissection?
A
Tear in intimal layer of the vessel, causing blood to enter the medial layer
18
Q
What type of aortic dissection requires emergent surgical intervention?
A
Ascending dissection
19
Q
What are the mortality rates associated with aortic dissection?
A
Overall mortality 27-58%
20
Q
What are the diagnostic tools for stable aortic dissection? Unstable?
A
Stable: CT, CXR, MRI, Angiogram
Unstable: echo (fastest)
21
Q
What main symptom is associated with aortic dissection?
A
severe sharp pain in posterior chest or back
22
Q
Ascending Dissection: Mortality increases by __ per __
A
1-2% per hour
23
Q
What are the classes for aortic aneurysm-dissection?
A
Stanford Class A, B; DeBakey Class 1,2,3
24
Q
What is the characteristic of a Stanford A aortic dissection classification?
A
tear in the ascending aorta
25
What is the characteristic of a Stanford B aortic dissection classification?
tear in the descending aorta
26
What are characteristics of DeBakey I, II, and III?
I: tear in ascending aorta, propogates to arch
II: tear confined to ascending aorta
III: tear in descending aorta
27
What should be considered for all patients with acute dissection involving the ascending aorta?
Surgery
28
What are the most commonly performed procedures for acute dissection involving the ascending aorta?
Replacement of aorta and aortic valve
29
What surgery techniques are utilized for aortic arch dissection surgery?
* circulatory arrest 30-40 min
* profound hypothermia (15-18º)
* cardiopulmonary bypass
30
How can patients with an acute, uncomplicated type B aortic dissection be treated?
Medical therapy
31
What does medical therapy for type B aortic dissection involve?
Intraarterial monitoring of SBP, UOP, drugs for BP control
32
What is the in-hospital mortality rate for patients with uncomplicated type B aortic dissection treated with medical therapy?
10%
33
What is the long-term survival rate at 5 years for patients with medical therapy only for type B aortic dissection? 10 years?
5 yr: 60-80%
10 yr: 40-50%
34
When is surgery indicated for patients with type B aortic dissection?
Signs of impending rupture, ischemia, organ failure
35
What is the in-hospital mortality rate associated with surgical treatment of distal aortic dissection?
29%
36
How are ascending aortic arch dissections typically treated?
Emergent surgery
37
How are descending arch aortic dissections usually treated?
Rarely with urgent surgery
38
What is the management approach for uncomplicated type B aortic dissections?
Admitted for BP control
39
What symptoms may indicate an impending rupture of an aortic dissection?
Posterior pain, HoTN, Left side hemothorax
40
What are risk factor for aortic dissections? (6)
HTN
atherosclerosis
aneurysms
fam history
cocaine use
inflammatory disease
41
Name two inherited disorders that increase the risk for aortic dissections.
Marfan's, Ehlers-Danlos
42
When is dissection more common in pregnant women?
3rd trimester
43
What are iatrogenic causes of aortic dissection related to?
Cardiac catheterization, aortic manipulation, cross clamping & arterial incision
44
What are the predisposing factors for aortic aneurysm?
HTN, atherosclerosis, age, male, smoking, family history
45
What are the common symptoms of aortic aneurysm?
May be asymptomatic or present with pain from compression
46
When is elective surgical repair recommended for aortic aneurysm?
Diameter >6 cm or rapidly enlarging aneurysms
47
What is the preferred management for aortic aneurysm patients at high risk?
Endovascular repair
48
What is aortic dissection characterized by?
Blood entry into the media
49
What is the typical presentation of aortic dissection?
Severe sharp pain in the posterior chest or back
50
How is Type A aortic dissection managed?
Acute surgical emergency
51
How is Type B aortic dissection managed?
If uncomplicated, medical management can be pursued
52
What triad of symptoms is experienced in about half of aortic aneurysm rupture cases?
Hypotension, back pain, pulsatile abdominal mass
53
Where do most abdominal aortic aneurysms rupture into?
Left retroperitoneum
54
Why may exsanguination be prevented in aortic aneurysm ruptures?
Clotting and tamponade effect in the retroperitoneum
55
What should be deferred until the rupture is surgically controlled in aortic aneurysm ruptures?
Euvolemic resuscitation
56
Why can euvolemic resuscitation without controlling bleeding be dangerous in aortic aneurysm ruptures?
May lead to loss of tamponade, further bleeding, hypotension, death
57
What is required for patients in unstable condition with suspected ruptured abdominal aortic aneurysm?
Immediate operation without preoperative testing or volume resuscitation
58
What are the 4 primary causes of mortality related to surgeries of the thoracic aorta?
MI, Respiratory failure, Renal failure, Stroke
59
What tests are included in a cardiac evaluation on the thoracic aorta?
stress test, echo, radionuclide imaging
60
What conditions may preclude a patient from AAA resection?
Severe reduction in FEV1 or renal failure
61
What are predictors of post-aortic surgery respiratory failure?
Smoking/COPD
62
What can be considered to help prevent post-aortic surgery respiratory complications?
bronchodilators, abx, chest physiotherapy
63
What is the most important indicator of post-aortic surgery renal failure?
Preop renal dysfunction
64
What should be avoided preoperatively to prevent renal failure?
Hypovolemia, HoTN & low cardiac output
65
What type of drugs should be avoided preoperatively?
Nephrotoxic drugs
66
What is recommended for patients with severe carotid stenosis?
Workup for CEA before elective surgery
67
What is anterior spinal artery syndrome?
Lack of blood flow to anterior spinal artery
68
What does the anterior spinal artery perfuse?
Anterior 2/3 of spinal cord
69
What are the consequences of ischemia in anterior spinal artery syndrome?
Loss of motor function, diminished pain/temp sensation, autonomic dysfunction
70
Why is anterior spinal artery syndrome the most common form of spinal cord ischemia?
Minimal collateral perfusion
71
How is the posterior spinal cord different in terms of perfusion?
Perfused by two posterior spinal arteries (better collateral)
72
What are some common causes of anterior spinal artery syndrome?
Aortic aneurysm, aortic dissection, atherosclerosis, trauma
73
What are the two main types of Cerebral Vascular Accidents?
Ischemic (87%) and Hemorrhagic (13%)
74
What is a significant predictor of CVA?
Carotid dz
75
What is the 1st leading cause of disability in the US?
CVA
76
TIA is a subset of what?
Self-limited ischemic strokes
77
What is the usual timeframe for symptoms to resolve in TIA?
Within 24h
78
How much greater is the risk of subsequent stroke in individuals who had a TIA?
10x
79
What diagnostic test can identify vascular occlusion in carotid disease?
Angiography
80
What are inherited risk factors for stroke? (5)
age
Male
Black race
hx stroke
sickle cell
81
What are modifiable risk factors for stroke? (8)
HTN
smoking
diabetes
carotid disease
afib
HF
↑Cholesterol
obesity
82
What carotid diagnostic tests are less invasive options for carotid disease and may identify aneurysms and AVMs?
CT & MRI
83
Which diagnostic test can provide indirect evidence of vascular occlusions with real-time bedside monitoring in carotid disease?
Transcranial doppler US
84
What can carotid auscultation identify in carotid disease?
Bruits
85
Where does carotid stenosis commonly occur due to turbulent blood flow at the branch-point?
Internal/external carotid bifurcation
86
What should the workup for carotid disease include evaluating for as potential sources of emboli?
A-fib, heart failure, valvular vegetation, or paradoxical emboli in the setting of PFO
87
What does the AHA recommend for the TPA treatment of CVA?
TPA within 4.5 hours
88
What is a surgical option for severe carotid stenosis?
Carotid Endarterectomy (CEA)
89
What are alternatives to Carotid Endarterectomy?
* Carotid stenting
* Interventional radiology (thrombolysis, thrombectomy)
90
What are some components of ongoing medical therapy for treating CVA? (5)
Antiplatelet tx
Smoking cessation
BP control
Cholesterol control
Diet & Physical activity
91
What is the importance of establishing preoperative deficits in patients undergoing carotid endarterectomy (CEA)?
Helps in neurologic evaluation
92
Why is monitoring blood pressure important during CEA surgery?
Optimizes cerebral perfusion pressure
93
What should be considered when a patient has severe carotid artery disease along with severe coronary artery disease?
most compromied area should take priority
94
What factors can affect cerebral oxygenation according to the text?
MAP
COP
SaO2
HGB
PaCO2
95
What 2 factors can affect cerebral oxygen consumption?
Temperature, Anesthesia
96
What does Peripheral Artery Disease result in?
Compromised blood flow to extremities
97
How is Peripheral Artery Disease defined?
ankle-brachial index (ABI) <0.9
98
What is the ankle-brachial index (ABI)?
Ratio of SBP @ ankle : SBP @ brachial artery
99
What is chronic hypo-perfusion in PAD typically due to?
Atherosclerosis
100
What are acute occlusions in PAD typically due to?
Embolism
101
How does the incidence of PAD change with age?
Increases, exceeding 70% by age 75
102
What is the risk of MI & CVA in patients with PAD compared to general population?
3-5x increased risk
103
What are the risk factors for Peripheral Artery Disease? (7)
Advanced age
Family hx
Smoking
DM
HTN
Obesity
↑ cholesterol
104
What are some signs and symptoms of Peripheral Artery Disease? (7)
Intermittent claudication, Resting extremity pain, Decreased pulses, Subcutaneous atrophy, Hair loss, Coolness, Cyanosis
105
How can relief be achieved for symptoms of Peripheral Artery Disease?
Relief with hanging lower extremity over side of bed (increases hydrostatic pressure)
106
What does Doppler U/S provide and identify in the diagnosis of Peripheral Artery Disease?
Pulse volume waveform identifies arterial stenosis
107
What can Duplex U/S identify in the diagnosis of Peripheral Artery Disease?
Plaque formation, calcification
108
How can Transcutaneous oximetry help in diagnosing Peripheral Artery Disease?
Assess tissue ischemia severity
109
What is the role of MRI w/contrast angiography in Peripheral Artery Disease management?
Guide endovascular intervention
110
What are the 4 components of Medical Tx for Peripheral Artery Disease?
Exercise, BP, cholesterol, glucose control
111
When is revascularization indicated in Peripheral Artery Disease?
Disabling claudication or ischemia
112
What surgical procedures are used for revascularization in Peripheral Artery Disease?
Arterial bypass, endovascular repair
113
What are common causes of acute artery occlusion? (2)
Left atrial thrombus (afib), left ventricular thrombus (post MI)
114
What are less common thrombus causes of acute artery occlusion? (3)
Valvular heart disease, endocarditis, PFO
115
What are noncardiac causes of acute artery occlusion? (4)
Atheroemboli, plaque rupture, hypercoagulability, trauma
116
What are the symptoms of acute artery occlusion? (6)
Limb ischemia
pain/paresthesia
weakness
decreased peripheral pulses
cool skin
color changes distal to occlusion
117
How is acute artery occlusion diagnosed?
Arteriography
118
What is the treatment for acute artery occlusion?
Surgical embolectomy, anticoagulation, amputation (last resort)
119
What is Subclavian Steal Syndrome?
Occluded SCA causing vertebral artery blood flow diversion from brain stem
120
What are the symptoms of Subclavian Steal Syndrome? (5)
Syncope
vertigo
ataxia
hemiplegia
ipsilateral arm ischemia
121
What are 3 risk factors for Subclavian Steal Syndrome?
**Atherosclerosis**
Takayasu arteritis
Aortic surgery
122
What is the curative treatment for Subclavian Steal Syndrome?
SC endarterectomy
123
What 2 assessment findings might be associated with subclavian steal syndrome?
Affected arm SBP ↓20mmHg
Bruit over SCA
124
What is Raynaud's Phenomenon?
Episodic vasospastic ischemia of the digits
125
Who does Raynaud's Phenomenon affect more, women or men?
affects women > men
126
What are some symptoms of Raynaud's Phenomenon?
Digital blanching or cyanosis w/cold exposure or SNS activation
127
How is Raynaud's Phenomenon diagnosed?
Based on history & physical
128
What are 3 treatment options for Raynaud's Phenomenon?
Protection from cold
CCBs
alpha-blockers
129
In which cases is surgical sympathectomy considered for Raynaud's Phenomenon?
For severe ischemia
130
What are 3 common PVD processes that can occur during surgery?
Superficial thrombophlebitis
Deep vein thrombosis
Chronic venous insufficiency
131
Why is DVT a major concern during surgery?
Can lead to PE, a leading cause of perioperative M & M
132
What are the 3 major factors of Virchow's Triad that predispose to venous thrombosis?
Venous stasis
Hypercoagulability
Disrupted vascular endothelium
133
Superficial thombophlebitis and DVT occur in approximately 50% of what kind of surgery?
total hip replacement
134
What are some risk factors for DVT? (5)
>age 40
surgery >1h
cancer
ortho surgeries on pelvis & LEs
abdominal surgery
135
What 3 diagnostic tools are useful for detecting thrombosis?
Doppler U/S
Venography
Impedance plethysmography
136
What prophylactic measures can be taken to prevent thrombosis?
SCD’s
SQ heparin 2-3x/day
Regional anesthesia (d/t early ambulation)
137
What are some moderate-risk medical conditions for developing deep vein thrombosis?
postpartum period
MI
CHF
138
What are some high-risk factors for developing deep vein thrombosis?
Hx thombosis, stroke
Extensive trauma
Major fractures
Knee or hip replacement
139
What are the recommended steps to minimize deep vein thrombosis?
Compression stockings
Early ambulation
anticoagulants
IVC
140
How can deep vein thrombosis be diagnosed?
Compression ultrasonography or impedance plethysmography
141
What should be done if deep vein thrombosis is suspected but US is normal?
Repeat imaging on days 2 and 7
142
When can deep vein thrombosis be ruled out?
If no abnormalities are found on US and normal repeat US
143
Which anticoagulants are used for Deep Vein Thrombosis (DVT) treatment?
Warfarin + Heparin or LMWH
144
What are the advantages of LMWH over unfractionated heparin?
* Longer half-life
* more predictable dose response
* doesnt require serial aPTT
* Less risk of bleeding
145
What are the disadvantages of LMWH?
* higher cost
* no reversal agent
146
What is the recommended INR range when Warfarin is used for DVT treatment?
INR between 2-3
147
How long are PO anticoagulants typically continued after a DVT?
6 months or longer
148
In what situations may an IVC filter be placed for DVT patients?
Recurrent PE or contraindication to anticoagulants
149
What are the 2 main types of large-artery vasculitis?
Takayasu arteritis
Temporal (giant cell) arteritis
150
What is the primary vessel affected in Kawasaki disease?
Coronary arteries
151
What are examples of medium to small-artery vasculitis?
Thromboangiitis obliterans, Wegener granulomatosis, Polyarteritis nodosa
152
What is temporal (giant cell) arteritis?
Inflammation of arteries of the head and neck
153
What are the symptoms of temporal arteritis?
Unilateral: headache, scalp tenderness, jaw claudication
154
Why is prompt initiation of corticosteroids indicated in temporal arteritis visual symptoms?
To prevent blindness
155
How is temporal arteritis diagnosed?
Biopsy of temporal artery shows arteritis in 90% of patients
156
What is Thromboangiitis Obliterans also known as?
Buerger Disease
157
What is Thromboangiitis Obliterans?
autoimmune inflammatory vasculitis ⇒ small/medium vessel occlusion in extremities
158
What triggers the autoimmune response in Buerger Disease?
Nicotine
159
What is the most predisposing factor for Buerger Disease?
Tobacco use
160
Who is Buerger Disease most prevalent in?
Men <45
161
What are the 5 diagnostic criteria for Buerger Disease?
* Hx smoking
* onset before 50
* infrapopliteal arterial occlusive disease
* upper limb involvement
* absence of risk factors for atherosclerosis
162
How is the diagnosis of Buerger Disease confirmed?
Biopsy of vascular lesions
163
What are the symptoms of Thromboangiitis Obliterans 'Buerger Disease'?
* forearm, calf, foot claudication
* Ischemia of hands & feet
* Ulceration and skin necrosis
* Raynaud's
164
What is considered the most effective treatment for Thromboangiitis Obliterans 'Buerger Disease'?
Smoking cessation
165
What are the anesthesia implications for Thromboangiitis Obliterans 'Buerger Disease'?
Meticulous positioning/padding
Avoid cold ⇒ Warm room
Prefer non-invasive BP
Conservative line placement
166
What is Polyarteritis Nodosa?
Antineutrophyl cytoplasmic antibody (ANCA) negative vasculitis
167
What are possible associations of Polyarteritis Nodosa?
Hepatitis B, Hepatitis C, Hairy Cell Leukemia
168
What are some complications of Polyarteritis Nodosa?
Glomerulonephritis
myocardial ischemia
peripheral neuropathy
seizures
169
What is the primary cause of death in Polyarteritis Nodosa?
Renal failure
170
How is Polyarteritis Nodosa treated?
Steroids, cyclophosphamide, treating underlying cause
171
What coexisting conditions should anesthesia consider in Polyarteritis Nodosa patients?
Renal disease, cardiac disease, hypertension
172
What are 2 mild symptoms of lower extremity chronic venous disease?
Telangiectasias, varicose veins
173
What are 3 severe symptoms of lower extremity chronic venous disease?
Edema, skin changes, ulceration
174
What are some risk factors for lower extremity chronic venous disease?
Advanced age
family hx
pregnancy
obesity
smoking
prolonged standing
175
What are the diagnostic criteria for Lower Extremity Chronic Venous Insufficiency?
Leg pain, heaviness, fatigue. Ultrasound showing venous reflux.
176
What is the initial treatment for Lower Extremity Chronic Venous Insufficiency?
Leg elevation
exercise
weight loss
compression therapy
skin barriers/emollients
steroids
wound management.
177
What are some conservative medical management options for Lower Extremity Chronic Venous Disease?
Diuretics
Aspirin
Antibiotics
Prostacyclin analogues
Zinc sulfate
178
When can ablation be considered for Lower Extremity Chronic Venous Disease?
If medical management fails
179
What are the methods of ablation for Chronic Venous Disease?
Thermal ablation w/laser, Radiofrequency ablation, Endovenous laser ablation, Sclerotherapy
180
What are the indications for ablation in Chronic Venous Disease?
Venous hemorrhage, Thrombophlebitis, Symptomatic venous reflux
181
What are the contraindications for ablation in Chronic Venous Disease?
Pregnancy, Thrombosis, PAD, Limited mobility, Congenital venous abnormalities
182
What are some surgical interventions for Lower Extremity Chronic Venous Disease?
Saphenous vein inversion
High saphenous ligation
Ambulatory Phlebectomy
Transilluminated-powered phlebectomy
Venous ligation
Perforator ligation
183
What is the leading cause of perioperative morbidity and mortality in noncardiac surgery?
Cardiac complications
184
Which group of patients has a higher incidence of cardiac complications during surgery?
Patients undergoing vascular surgery
185
In patients with peripheral arterial disease, what is their increased risk of cardiovascular ischemic events compared to those without?
3-5 times greater risk
186
What luminal diameter percentage represents significant stenosis in the carotid artery based on studies?
70-75%
187
What can occur if collateral cerebral blood flow is inadequate in carotid artery stenosis?
TIAs and ischemic infarction
188
What blood pressure abnormalities can be observed during and after carotid endarterectomy?
Hypertension and hypotension
189
What is the typical cause of acute arterial occlusion?
Cardiogenic embolism
190
What can cause cardiogenic embolism?
Thrombus in the left ventricle due to MI or dilated cardiomyopathy
191
List some cardiac causes of systemic emboli.
Valvular heart disease, prosthetic heart valves, infective endocarditis, left atrial myxoma, Afib, atheroemboli
192
What is Thromboangiitis obliterans?
An inflammatory vasculitis leading to occlusion of small and medium-sized arteries and veins in the extremities
193
What prophylactic measures do patients at low risk for DVT require?
Early ambulation, compression stockings
194
Which patients may have a higher risk of DVT?
>40 y/o
surgery >1 hour
LE orthopedic
pelvic or abdominal surgery
Prolonged bedrest
195
What is an improvement seen with endovascular repair of aortic lesions?
Significant perioperative mortality improvement
