Vascular Disease (Exam III) Flashcards
(85 cards)
1
Q
What are some coexisting diseases that are commonly seen in vascular surgery patients? Which 3 are the MOST common?
A
- CAD - 40-80% of vasc patient have this
- HTN- (most common)
- Diabetes- (most common)
- Smokers- (most common)
- CNS atherosclerosis
- Renal
Good to know - From Brooke
2
Q
What are the 3 main arterial Pathologies?
A
aneurysms, dissections, occlusions
- Aorta and its branches are more likely to be affected by aneurysms and dissections
- Peripheral arteries are more likely to be affected by occlusions
slide 3
3
Q
2 types of aortic aneurysms
A
- fusiform: uniform dialation along the entire corcumference of the arterial wall
- saccular: berry-shaped bulge to one side
slide 4
4
Q
Signs and symptomes of aortic aneurysms, and diagnostic tools
A
- s/s: can be asymptomatic or can have pain due to surrounding compression
- diagnostic tools: CT, MRI, CXR, angiogram, echo (in a suspected dissection, a doppler echocardiogram is the fastest and safest measure to diagnose)
slide 4
5
Q
Treatment of aortic aneurysms
A
- Medical management to ↓expansion rate
- Manage BP, Cholesterol, stop smoking
- Avoid strenuous exercise, stimulants, stress
- Regular monitoring for progression
- Surgery indicated if >5.5 cm, growth >10mm/yr, or a family history of dissection
- Endovascular stent repair has become a mainstay over open surgery w/graft
slide 5
6
Q
What are the risk factors for vascular disease?
A
- Diabetes mellitus
- Dyslipidemia
- Family history
- Hypertension
- Obesity
- Older age: 75 y/o and up
- Smoking (2x)
7
Q
In a patient with vascular disease what other issues should we be sure to evaluate in preop? Why does it matter?
A
- CAD
- pulm dysfunction
- renal dysfunction
- neuro dysfunction
- endocrine dysfunction
- Matters d/t disease process not being limited to arterial beds in periphery → its everywhere
from Brooke, good to know
8
Q
What is the primary goal for invasive monitoring of a vascular surg patient?
A
To detect cardiac problems; a-line might be necessary
from Brooke
9
Q
Peripheral Venous Disease (common processes that occur during surgery)
A
- Superficial thrombophlebitis
- Chronic venous insufficiency
- DVT- major concern bc it can lead to PE, a leading cause of perioperative M & M
- Virchows Triad: 3 major factors that predispose to venous thrombosis
Venous stasis
Hypercoagulability
Disrupted vascular endothelium
Sldie 30
10
Q
Superficial Thrombophlebitis and DVT are common in surgery.
Occur in approximately _ total hip replacements
Normally _ and usually _
* Risk factors for DVT:
A
- 50%
- subclinical and usually completely resolve
- Risk factors: >age 40, surgery >1h, cancer, ortho surgeries on pelvis & LEs, abdominal surgery
slide 31
11
Q
Diagnostics and Prophylactic measures for SVT and DVT
A
- Diagnostics: Doppler U/S sensitive for detecting proximal thrombosis > distal thrombosis, Venography and impedance plethysmography are also useful diagnostic tools
-
Prophylactic measures: SCD’s, SQ heparin 2-3x/day
Regional anesthesia can greatly ↓risk d/t earlier postop ambulation
slide 31
12
Q
DVT treatment
A
- Anticoagulation: Warfarin + Heparin or LMWH
- Warfarin (vit K antagonist) is initiated during heparin treatment and adjusted to achieve INR btw 2-3
- Heparin discontinued when Warfarin achieves therapeutic effect
- PO anticoagulants continued 6 months or longer
An IVC filter may be placed in pts w/ recurrent PE, or have contraindication to anticoagulants
slide 34
13
Q
LMWH advantages and disadvantages
A
-
Advantages: longer HL & more predictable dose response,
doesn’t require serial assessment of activated partial thromboplastin time, Less risk of bleeding - Disadvantages: Higher cost, Lack of reversal agent
slide 34
14
Q
What causes intermittent claudication?
A
- When O₂ demand exceeds supply
from Brooke
15
Q
When might revascularization for PVD be considered?
A
- Disabling claudication
- Ischemic rest pain
- Impending limb loss
from Brooke
16
Q
What are risk factors for stroke?
A
- Age;
- Atrial fibrillation;
- Black race;
- History/family history;
- HTN/smoking/diabetes;
- Hypercholesterolemia;
- Male;
- Obesity;
- Sickle cell disease
from brooke
17
Q
What are some ways we might diagnose a stroke?
A
- Angiography;
- Carotid bruit with auscultation
- Carotid stenosis;
- Sudden neurological deficits
slide 18 and 19
18
Q
Where does carotid stenosis most often occur? and what should our workup include?
A
Carotid bifurcation
due to turbulent blood flow at the branch point
* Workup includes: evaluation for sources of emboli (AFib), heart failure, valvular vegitation, or paradoxical emboli
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19
Q
Treatment of CVA
A
- AHA recommends TPA withing 4-5Hours
- IR
- Carotid Endarterectomy (CEA) - lumen diameter 1.5mm or >70% blockage
- Carotid stenting (alternative to CEA) major risk for microembolization
- Ongoing medical treatment: antiplatelet agents, smoking cessation, BP control, cholesterol control, diet and physical activity
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20
Q
CEA preop evaluation
A
- Neuro eval
- CV disease (CAD is prevalent, MI is a major cause of complications in the OR_)
- HTN is common - establish an acceptable BP range
- CPP=MAP-ICP
- Maintain collateral flow through stenotic vessels
- extreme head rotation may compress blood flow
- cerebral oximetry divices to determine perfusion
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21
Q
Cerebral oximetry - real time data
A
Effected by: MAP, CO,SaO2, HGB, PaCO2
cerebral O2 consumption effected by: temp and anesthesia
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22
Q
Peripheral artery disease
A
Compromised blood flow to the extremities
* defined by ankle-brachial index (ABI) <0.9
* ratio = SBP at ankle: SBP at brachilal artery
* chronic hypoperfusion due to atherosclerosis or vasculitis
slide 23
23
Q
PAD acute occlusions are typically due to _
Incidence of PAD increases with _, exceeding 70% by _
Atherosclerosis is _, a pt with PAD has _ increased risk of _ and _
A
- embolism
- age 70
- systemic, 3-5x, MI and CVA
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24
Q
Peripheral Artery disease Risk factors
A
- advanced age
- family history
- smoking
- DM
- HTN
- obersity
- increased cholesterol
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Peripheral artery disease signs and symptoms
* intermittent claudication
* resting extremity pain
* decreased pulses
* subcutaneius atrophy
* hair loss
* coolness
* cyanosis
* *relief with hanging lower extremity over the side of the bed to increase hydrostatic pressure*
| slide 24
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Diagnosis and treatment of PAD
Diagnosis: Doppler US, Duplex US (can ID areas of plaque formation), transcutansius oximetry, MRI with contrast to guide intervention or sugical bypass
Treatement: exercise, BP cholesterol and glucose control, revascularization is indicated with disabling claudication
* surgical reconstruction - bypass
* endovascular repair - transluminal angioplasty or stent placement
| slide 25
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Acute artery occlusion (due to what? and causes)
frequently d/t cardiogenic embolism
* common causes: Left atrial thrombus arising from Afib, Left ventricular thrombus arising from dilated cardiomyopathy after MI
* Less common causes: valvular heart dz, endocarditis, PFO, atheroemboli, plaque rupture, hypercoagulability, trauma
| slide 26
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Acute artery occlusion (s/s, diagnosis and treatment)
* s/s: limb ischemia, pain/paresthesia, weakness, ↓peripheral pulses, cool skin, color changes distal to occlusion
* Diagnosis: Arteriography
* Treatment: Surgical embolectomy, anticoagulation, amputation (last resort)
| slide 26
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Subclavian Steal Syndrome (definition, s/s)
* occluded SCA, proximal to vertebral artery causing vertebral artery blood flow to be diverted away from brainstem
* s/s: Syncope, vertigo, ataxia, hemiplegia, ipsilateral arm ischemia
**Effected arm SBP may be ̴20mmhg lower**
Bruit over subclavian artery
| slide 27
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Subclavian steal syndrome (risk factors and treatment)
Risk factors: Atherosclerosis, Takayasu Arteritis, aortic surgery
Treatment: stents or sx (its curative)
| slide 27
31
Raynaud's Phenomenon (definition, s/s)
**Episodic vasospastic ischemia of the digits**
Effects women > men
May appear with CREST syndrome (scleroderma subtype)
* S/S: digital blanching or cyanosis w/cold exposure or SNS activation
| slide 29
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Raynaud's Phenomenon (diagnosis and treamtent)
* Diagnosis: based on history and physical
* Treamtent: protection from cold, CCB's, alpha blockers, Surgical sympathectomy for severe ischemia
| slide 29
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Carotid disease diagnostic testing
* angiography
* CT/MRI
* Transcranial doppler US: may give indirect evidence of vascular occlusions
* carotid auscultation
* carotid US
| slide 19
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Systemic Vasculitis (definition)
* 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
| slide 35
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Systemic Vasculitis (size of artery inclusions)
* Large artery vasculitis: Takayasu arteritis, Temporal (or giant cell) arteritis
* Medium Artery: Kawasaki disease (most often in the coronary arteries)
* medium/small artery: thromboangiitis obliterans, Wegener granulomatosis, polyarteritis nodosa
*Additionally, vasculitis can be a feature of connective tissue diseases such as systemic lupus erythematosus and rheumatoid arthritis*
| slide 35
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Temporal (Giant Cell) Arteritis (Definition, s/s)
Inflammation of arteries of the head and neck
* S/S: unilateral; headache, scalp tenderness, jaw claudication
Opthalmic Arterial branches may lead to ischemic optic neuritis and unilateral blindness
| slide 36
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Temporal (Giant Cell) Arteritis (Treatment and Diagnostics)
* Treatment: Prompt initiation of corticosteroids indicated for visual symptoms, to prevent blindness
* Diagnosis: Biopsy of temporal artery shows arteritis in 90% of pts
| Slide 36
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Thromboangiitis Obliterans "Buerger Disease" (Definition and predisposing factors)
* Inflammatory vasculitis leading to small & medium vessel occlusions in the extremities (Autoimmune response triggered by nicotine)
* Tobacco use is most predisposing factor, Most prevalent in men <45
| Slide 37
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Thromboangiitis Obliterans "Buerger Disease" (5 diagnostic criteria)
5 diagnostic criteria:
* h/o smoking
* onset before 50
* infrapopliteal arterial occlusive dz
* upper limb involvement
* Absence of risks factors for atherosclerosis (outside of tobacco)
*Diagnosis confirmed w/biopsy of vascular lesions*
| Slide 37
40
Thromboangiitis Obliterans "Buerger Disease" S/S
* forearm, calf, foot claudication
* Ischemia of hands & feet
* Ulceration and skin necrosis
* Raynaud's is commonly seen
| Slide 38
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Thromboangiitis Obliterans "Buerger Disease" Treatment and Anesthesia implications
* Treatment: Smoking cessation-most effective tx, Surgical revascularization
*No effective pharmacological tx*
* Anesthesia Implications: Meticulous positioning/padding, Avoid cold; Warm the room and use warming devices, Prefer non-invasive BP and conservative line placement
| Slide 38
42
Poluarteritis Nodosa (Definitiaon, associations, and cause of death)
* Small & medium arteries involved, Inflammation results in glomerulonephritis, myocardial ischemia, peripheral neuropathy and seizures
* May be assoc w/ Hep B, Hep C, or Hairy Cell Leukemia
* **Renal failure is the primary cause of death**
* HTN geerally caused by renal disease
| Slide 39
43
_ is negative result in Polyarteritis Nodosa
Antineutrophyl cytoplasmic antibody (ANCA) negative vasculitis
| slide 39
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Polyarteritis Nodosa Treatments and anesthesia considerations
* Treatment: steroids, cyclophosphamide, treating underlying cause (cancer)
* Anesthesia Implications: consider coexisting renal dz, cardiac dz, and HTN, Steroids likely beneficial
| slide 39
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Lower Extremity Chronic Venous Disease (Definition and s/s with ranges)
* Long standing venous reflux & dilation
* Effects 50% of the population
Ranges mild-severe
* Mild sx: telangiectasias, varicose veins
* Severe sx: edema, skin changes, ulceration
| Slide 40
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Risk factors for Chronic Venous Disease (11)
advanced age
family hx
pregnancy
ligamentous laicity
previous venous thrombosis
LE injuries
prolonged standing
obesity
smoking
sedentary lifestyle
high estrogen levels
| Slide 40
47
Lower extremity chronic venous insufficiency (diagnosis and treatment)
* Diagnosis: Sx of leg pain, heaviness, fatigue, Confirmed by ultrasound showing venous reflux, Retrograde blood flow > 0.5 seconds
* Treatment: initially conservative
Leg elevation
Exercise
Weight loss
Compression therapy
Skin barriers/emollients
Steroids
Wound management
| Slide 41
48
Lower Extremity Chronic Venous Disease Medical management
Diuretics
Aspirin
Antibiotics
Prostacyclin analogues
Zinc sulphate
*If management fails, ablation may be performed
| slide 42
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Ablation for chronic venous disease (methods, indication, contraindications)
* Methods: Thermal ablation w/laser, Radiofrequency, ablation, Endovenous laser ablation, Sclerotherapy
* Indications: Venous hemorrhage, Thrombophlebitis, Symptomatic venous reflux
* Contraindications: Pregnancy, Thrombosis, PAD, Limited mobility, Congenital venous abnormalities
| slide 43
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Surgical Intervention for Lower Extremity Chronic Venous disease
Surgical intervention-usually last resort
Procedures:
Saphenous vein inversion
High saphenous ligation
Ambulatory Phlebectomy
Transilluminated-powered phlebectomy
Venous ligation
Perforator ligation
| slide 44
51
What are two sources of possible major complications for anesthesia during aorta repair surgery?
* Aortic cross-clamping
* Intraoperative blood loss
| from Brooke
52
Ascending Aortic Dissection
Catastrophic - requires emergent surgical intervention
* Stanford A, or Debakey 1&2, mortality increases 1-2% per hour
* overall mortality: 27-58%
| slide 6
53
How are aortic dissections classified?
* DeBakey I II III;
* --OR--;
* Stanford A (proximal) or B (Distal)
54
Describe each of the DeBakey classifications?
* DeBakey I → Dissection in the ascending aorta that extends into the descending aorta;
* DeBakey II → Dissection in the ascending aorta that does not extend into the descending aorta;
* Debakey III → Dissection in the descending aorta distal to left subclavian;
* Debakey IIIA → extension to abdominal aorta;
* Debakey IIIB → doesn't extend to abdominal aorta
55
What is an aortic dissection?
* Characterized by a spontaneous tear of the vessel wall intima permitting the passage of blood along false lumen - this causes blood to enter the medial layer
| slide 6
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What is the most common factor contributing to the progression of an aortic dissection? Most serious complication is?
* Common factor = HTN;
* Complication = aneurysm rupture
| from Brooke
57
Stanford classification Type A Dissection in ascending aortia
* 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
| slide 8
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Stanford A Dissection of 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
* current surgical techniques: period of circulatory arrest (30-40 min)
* body temp: 15-18 degrees C
* *Neurologic defects are the major complications associated with aortic arch replacement* (occur in 3-18% of pts)
| slide 9
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Stanford B dissection of descending thoracic aorta medical therapy
* 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
* in hospital mortaility rate of 10%
* The long-term survival rate with medical therapy only is 60-80% at 5 years and 40-50% at 10 years
* Medical therapy: intraarterial monitoring of SBP and UOP, drugs to contol BP, control contractility (beta blockers, cardene)
| slide 10
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Stanford B dissection surgical indications
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
| slide 10
61
What are the 3 layers of a vessel wall?
* Tunica externa (outer);
* Tunica Media (middle);
* Tunica interna (inner)
| good for us to know from Brooke
62
What is the normal size of the aorta in adults? When would an aortic resection be performed?
* normal = 2-3 cm in width;
* Electrive resection typ done when aneurysm is > 4 cm
| from brooke
63
When does a pseudoaneurysm form?
* when the intima and media are ruptured and only the adventitia or blood clot form the outer layer of the vessel
| from brooke
64
Comparison of Aortic Aneurysm and Aortic Dissection
65
What are risk factors for aortic dissections? (inherited and lifestyle)
Inherited disorders:
* marfans, Ehlers Danlos, Biscuspid aortic valve
Lifestyle:
* HTN
* atherosclerosis
* aneurysms
* family history
* cocaine use
* inflammaory disorders
| slide 12
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What are some S/Sx of a thoracic aneurysm?
* Often asymptomatic and but exam can find:;
* Hoarseness;
* Stridor;
* Dyspnea;
* Dysphagia;
* Dilation of aortic valve annulus
| from brooke
67
What are some S/Sx of acute aortic dissection?
* Severe sharp tearing pain;
* Hypotension/hypertension;
* Absence of peripheral pulses;
* Paraplegia/paraparesis
| slide 6
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How do we diagnose aneurysms/aortic dissections?
Stable: CXR, CT, MRI, Angiogram
Unstable: Echo/TEE
| slide 6
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What is "anterior spinal artery syndrome"? What are some adverse S/E?
* caused by lack of blood flow to the anterior spinal artery
* The anterior spinal artery is responsible to perfusing the anterior 2/3 of the spinal cord
* Ischemia leads to: loss of motor function below the infarct, diminished pain/temp/sensation below infarct, autonomic dysfuntion (HoTN and loss of bowel/bladder function)
| slide 17
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Anterior spinal artery syndrome is _ because the anterior spinal artery has _which makes it vunerable. What perfuses it? commmon causes?
* the most common form of spincal cord ischemia
* minimal collateral perfusion
*
* Perfused by: two posterior spinal arteries
* Common causes: aortic aneurysms, aortic dissection, atherosclerosis, trauma
| slide 17
71
What famous artery perfuses the anterior spinal artery?
* Artery of Adamkiewicz or the greater radiculmedullary artery
| from brooke
72
If you notice a patient has a pulsatile abdominal mass on exam what would you suspect?
* Abdominal aneurysm → common in people > 60 y/o
73
What are the classic S/Sx of an abdominal aneurysm rupture (triad)?
**Hypotension, Back pain, Pulsatile mass**
* most rupture to the left retroperitonrum
| slide 14
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Are aortic Aneurysm Ruptures always emergent surgeries?
Not always!
* Clotting or tamponade effect can prevent exanguination
* euvolemic resuscitation may be deferred until rupture is surgically controlled: without bleeding control, loss of tamponade can happen with increase of BP
* if unstable with suspected ruptured AAA - those require emergent surgery without preop testing
| slide 14
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Preopertive Evaluation of suspected Aortic dissestion or aneurysm (4 primary causes of mortaility)
***4 primary causes: MI,
respiratory failure,
renal failure,
stoke***
* Assess for CAD, valve dysfunction, heart failure
* IHD may require intervention prior to surgery
* are you able to do cardiac tests first? stress, echo etc
* **severe reduction in FEV1 or renal failure may preclude a pt from AAA resection**
* smoking and COPD = high predictor of respiratory failure
| slide 15
76
What is the most important factor of post-aortic surgery renal failure? and how do we decrease it?
* preop renal dysfunction
* we try to hydrate, avoid hypovolemia, hypotension and low CO and avoid nephrotoxic drugs
| slide 16
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What should we do if the pt has a history of a stroke but has a AAA?
* Carotid ultrasound
* angiogram of brachiocephalic and intracranial arteries
-with severe carotid stenosis: workup for CEA (carotid endarterectomy) before elective surgery
| slide 16
78
Surgery on the aortic arch and ascending aorta use what approach?
* Aortic arch → median sternotomy with deep hypothermic circulatory arrest;
* Ascending aortia → cardiopulm bypass
| added from brooke
79
Cerebral Vascular Accidents (percentages,
s/s and predictor)
* 87% Ischemic and 13% hemorrhagic
* we see sudden onset neuro deficits
* Prominent predictor: carotid disease
| side 18
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CVA is the _ leading cause of disability in the US and the _ leading cause of death in the US.
TIA are _ ischemic strokes and resolve in _ hours
TIAs have _ greater risk of subsequent stroke
* 1st cause of disability, 3rd cause of death
* self-limiting, 24 hours
* 10x greater
| slide 18
81
How do we calculate spinal cord perfusion pressure?
* Spinal Perf Pressure = MAP - SCP
| CPP was in our lecture
82
What are some protective therapeutic measures we can take before the surgeon cross clamps the aorta?
* Methylprednisolone;
* Mild hypothermia;
* Mannitol (0.5g/kg);
* Renal dose dopamine (1-3 mcg/kg/min);
* Fenoldopam (0.05-0.1 mcg/kg/min);
* Maintain BP;
* Drainage of CSF
| Not in our lecture, but good to know
83
Key points for lecture (read through)
* Cardiac complications are the leading cause of perioperative morbidity and mortality in patients undergoing noncardiac surgery
* The incidence of these complications is higher in patients undergoing vascular surgery
* Atherosclerosis is a systemic disease. Pts with peripheral arterial dz have a 3-5 times greater risk of cardiovascular ischemic events
* Data from transcranial doppler and carotid duplex ultrasound 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
| slide 45
84
Key points (read over)
* Both hypertension and hypotension may be observed frequently during and after carotid endarterectomy
* Acute arterial occlusion is typically caused by cardiogenic embolism. Emboli may arise from a thrombus in the left ventricle that develops because of MI or dilated cardiomyopathy
* Other cardiac causes of systemic emboli are valvular heart disease, prosthetic heart valves, infective endocarditis, left atrial myxoma, Afib, and atheroemboli
* Thromboangiitis obliterans is an inflammatory vasculitis leading to occlusion of small and medium-sized arteries and veins in the extremities
| slide 46
85
Key points (read over)
* Pts at low risk for DVT require minimal prophylactic measures such as early postop ambulation and compression stockings
* The risk of DVT may be much higher 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
* Endovascular repair of aortic lesions is a relatively new technique with significant improvements in perioperative mortality
* Endovascular arterial procedures have emerged as alternative, less invasive methods of arterial repair
| slide 47
