Vascular Diseases Flashcards
(115 cards)
1
Q
What are the 3 main arterial pathologies?
A
Aneurysms, dissections, occlusions
2
Q
Which part of the vascular system is more likely to be affected by aneurysms and dissections?
A
Aorta & its branches
3
Q
Peripheral arteries are more likely to be affected by _______.
A
Occlusions
4
Q
What defines an aortic aneurysm?
A
Dilation of all 3 layers of artery, leading to a >50% increase in diameter
5
Q
What is a significant risk associated with aortic aneurysm rupture?
A
75% mortality rate
6
Q
What are the two types of aortic aneurysms?
A
- Saccular: outpouching bulge to one side
- Fusiform: Uniform circumferential dilation
7
Q
What are common diagnostic tools for aortic aneurysms?
A
- CT
- MRI
- CXR
- Angiogram
- Echocardiogram
8
Q
*In suspected dissection, what is the fastest/safest measure for diagnosis?
A
Doppler echocardiogram
9
Q
What medical management can help reduce the expansion rate of an aortic aneurysm?
A
- Manage BP
- Cholesterol
- Stop smoking
- Avoid strenuous exercise, stimulants, stress
- Regular monitoring for progression
10
Q
*Surgery is indicated for aortic aneurysms at what diameter?
A
*>5.5 cm
*>10 mm/yr
*Family history of dissection
11
Q
What is the definition of aortic dissection?
A
Tear in intimal layer of the vessel, causing blood to enter the medial layer
12
Q
What is the mortality rate associated with ascending dissection?
A
Increases by 1-2% per hour
Overall 27-58%
13
Q
What are the classes of aortic dissections?
A
- Stanford Class A
- Stanford Class B
- DeBakey Class 1
- DeBakey Class 2
- DeBakey Class 3
14
Q
Which Stanford and Debakey classes of dissection requires emergent surgical intervention?
A
Stanford Class A
Debakey I&II
15
Q
What surgery is commonly performed for Stanford A/Debakey I&II dissections?
A
- Ascending aorta & aortic valve replacement with a composite graft
- Ascending aorta replacement with resuspension of the aortic valve
*Can’t just place a stent
16
Q
What is the primary treatment for uncomplicated type B/DeBakey III dissections?
A
Medical therapy which consists of
*Intraarterial monitoring of SBP and UOP
*Drugs to control BP and the force of LV contraction (BBs, Cardene, SNP)
17
Q
Descending thoracic Aorta:
A
An uncomplicated type B dissection with normal hemodynamics, no hematoma, and no branch vessel involvement can be treated medically
18
Q
Mortality and survival rates of Stanford B dissection?
A
-In-hospital mortality rate of 10%
-Long-term survival rate with medical tx is 60-80% at 5 yrs and 40-50% at 10 yrs
19
Q
When is surgery indicated for type B dissection?
A
Signs of impending rupture (persistent pain, hypotension, left-sided hemothorax) or compromised perfusion to the lower body
20
Q
What are the major risk factors for aortic dissection?
A
- HTN
- Atherosclerosis
- Aneurysms
- Family history
- Cocaine use
- Inflammatory diseases
21
Q
What are the inherited disorders associated with Aortic Dissections?
A
*Marfans
*Ehlers
*Danlos
*Bicuspid Aortic Valve
22
Q
Causes of dissection include:
A
*Blunt trauma
*Cocaine
*Iatrogenic (cardiac cath, aortic manipulation, cross-clamping, arterial incision)
23
Q
*What populations are dissections more common in?
A
Men
Pregnant women in their 3rd trimester
24
Q
What triad of symptoms is seen in about half of aortic aneurysm rupture cases?
A
- Hypotension
- Back pain
- Pulsatile abdominal mass
25
Where do most aortic aneurysms rupture into?
Left retroperitoneum
26
If retroperitoneal tamponade occurs, ___________ may be delayed until the rupture is surgically controlled, to maintain a ________and reduce risk of _____________
volume resuscitation
lower BP
further bleeding, hypotension, and death
27
What are the four primary causes of mortality related to surgeries of the thoracic aorta?
* MI
* Respiratory failure
* Renal failure
* Stroke
28
What is the anterior spinal artery syndrome (ASA syndrome) caused by?
Lack of blood flow to the anterior spinal artery
29
*What may preclude a patient from aortic surgery?
Renal failure
Low FEV1
30
What are the biggest predicators of post-aortic surgery respiratory failure?
*Smoking and COPD
*PFTs and ABGs help define risk
-Consider bronchodilators, abx, chest physiotherapy
31
What are the symptoms of anterior spinal artery syndrome?
* Loss of motor function below the infarct
* Diminished pain and temperature sensation below the infarct
* Autonomic dysfunction
32
What are the biggest predicators of post-aortic surgery renal failure and what interventions should we perform?
Preexisting renal dysfunction
*Preop hydration
*Avoid hypovolemia, HoTN & low cardiac output
*Avoid nephrotoxic drugs
33
What percentage of CVAs are ischemic?
87%
34
What causes ASA (Anterior Spinal Artery Syndrome)?
Lack of blood flow to the anterior spinal artery
35
What is a TIA?
Subset of self-limited ischemic strokes with symptoms that resolve within 24 hours
*have 10x greater recurrence of subsequent stroke
36
Why is ASA syndrome the most common form of spinal cord ischemia?
It has minimal collateral perfusion
37
What are common causes of ASA syndrome?
*Aortic aneurysms
*Aortic Dissections
*Athlersclerosis
*Trauma
38
What diagnostic tests can identify carotid disease?
* Angiography
* CT & MRI
* Transcranial doppler US
* Carotid auscultation
* Carotid US
39
*What is the recommended treatment for CVA according to the American Heart Association?
TPA within 4.5 hours of onset
40
What is the prominent predictor of CVA?
Carotid diseases
41
Inherited Risk Factors of CVA
*Age
*Hx of stroke
*Family hx of stroke
*Black race
*Male gender
*Sickle cell
42
Modifiable Risk Factors of CVA
*HTN
*Smoking
*DM
*Carotid artery disease
*A fib
*HF
*Hypercholesterolemia
*Obesity or physical inactivity
43
*LMWH Advantages over unfractionated heparin
*Longer HL & more predictable dose response
*Doesn’t require serial assessment of aPTT
*Less risk of bleeding
44
LMWH Disadvantages
*Higher cost
*Lack of reversal agent
45
What is the surgical treatment for severe carotid stenosis?
Carotid Endarterectomy (CEA)
46
What is considered severe carotid stenosis?
Lumen diameter 1.5mm or >70% blockage
47
What is the leading cause of disability in the US?
CVA
***it is also 3rd cause of death
48
Carotid Stenosis
Commonly occurs at the carotid bifurcation, due to turbulent blood flow at the branch-point
49
Medical therapy for CVA
*Antiplatelet tx
*Smoking cessation
*BP control
*Cholesterol control
*Diet & Physical activity
50
What is Raynaud’s phenomenon?
Episodic vasospastic ischemia of the digits that is more common in women
51
Tx for Raynaud's Phenomenon
*Protection from cold
*CCBs
*alpha-blockers
52
What is cerebral oxygenation affected by?
MAP
COP
Sa02
HGB
PaC02
53
What is cerebral O2 consumption affected by?
Temperature
Depth of anesthesia
54
Differences in PAD Diagnosis
Doppler U/S: provides a pulse volume waveform identifies arterial stenosis
Duplex U/S: can identify areas of plaque formation & calcification
Transcutaneous oximetry: can assess the severity of tissue ischemia
MRI w/contrast angiography: used to guide endovascular intervention or surgical bypass
55
What are the components of Virchow's Triad that predispose to venous thrombosis?
* Venous stasis
* Disrupted vascular endothelium
* Hypercoagulability
56
Peripheral Artery Disease
Compromised blood flow to the extremities defined by an ankle-brachial index (ABI) <0.9
57
Ankle-Brachial Index (ABI)
ABI= ratio of SBP @ ankle : SBP @ brachial artery
58
What typically causes chronic PAD?
Atherosclerosis
**since it is systemic, patients have 3-5x increased risk of MI & CVA
59
What are the common causes of acute peripheral artery occlusion?
* Left atrial thrombus due to Afib
* Left ventricular thrombus due to cardiomyopathy after MI
* Atheroemboli
* Plaque rupture
60
Risk Factors for PAD
Advanced age
Family hx
Smoking
DM
HTN
Obesity
↑Cholesterol
61
S/S of PAD
Intermittent claudication
Resting extremity pain
Weak pulses
Subcutaneous atrophy
Hair loss
Coolness
Cyanosis
*Relief w/hanging LE over side of bed (↑hydrostatic pressure)
62
Clinical Dilemma: severe carotid dz + severe coronary artery dz
Must stage cardiac revascularization and CEA
Most compromised area should take priority
63
What is the major concern associated with DVT?
Can lead to pulmonary embolism (PE)
64
Subclavian Steal Syndrome
Occluded SCA, proximal to vertebral artery so the vertebral artery flow diverts away from brainstem
65
Symptoms of SC steal
Syncope
Vertigo
Ataxia
Hemiplegia
Ipsilateral arm ischemia (effected arm SBP may be 20mmHg lower)
66
SC steal risk factors
Atherosclerosis
Hx of aortic surgery
Takayasu arteritis
67
What is the preferred treatment for superficial thrombophlebitis?
Usually resolves on its own
68
Common PVD processes that occur during surgery
Superficial thrombophlebitis
Deep vein thrombosis
Chronic venous insufficiency
69
DVT Risk factors
>40 y/o
Surgery >1 hr
Cancer
Ortho surgeries on pelvis and LE
Abdominal surgery
70
DVT Prophylaxis
Compression stockings
SCDs
SQ heparin 2-3x/day
**Regional anesthesia d/t earlier postop ambulation
71
DVT Treatment
Warfarin + heparin or LMWH
-Warfarin goal INR 2-3
-D/c heparin when warfarin reaches therapeutic dose
-PO anticoagulants continued for at least 6 months
72
What is the most effective treatment for thromboangiitis obliterans (Buerger Disease)?
Smoking cessation
-There is no effective pharmacological tx
73
Symptoms of Thromboangiitis Obliterans “Buerger Disease”
Forearm, calf, foot claudication
Ischemia of hands & feet
Ulceration and skin necrosis
Raynaud's is commonly seen
74
What is Thromboangiitis Obliterans “Buerger Disease”?
Autoimmune response to nicotine that leads to Inflammatory vasculitis of small & medium vessel occlusions in the extremities
75
Who is Thromboangiitis Obliterans “Buerger Disease” most prevalent in?
Men < 45
76
5 Diagnostic criteria of Thromboangiitis Obliterans “Buerger Disease”
1. Hx of smoking
2. Onset before 50
3. Infrapopliteal arterial occlusive dz
4. Upper limb involvement
5. Absence of risks factors for atherosclerosis (outside of tobacco)
77
Anesthesia implications for Thromboangiitis Obliterans “Buerger Disease”
Meticulous positioning/padding
Avoid cold; Warm the room and use warming devices
Prefer non-invasive BP and conservative line placement
78
What is the main characteristic of temporal (giant cell) arteritis?
Inflammation of arteries of the head and neck
79
What is the primary diagnostic method for temporal arteritis?
Biopsy of temporal artery
80
What is the treatment for visual symptoms in temporal arteritis?
Corticosteroids
81
What common diagnostic tool identifies arterial stenosis in PAD?
Doppler U/S
82
What is the main treatment for acute peripheral artery occlusion?
Anticoagulation, surgical embolectomy, amputation as last resort
83
What is the role of cerebral oximetry in surgical procedures?
Helps gauge and trend cerebral perfusion
84
What is systemic vasculitis?
Group of vascular inflammatory diseases characterized by the size of the vessels at the primary site of the abnormality
85
Large-artery vasculitis
Takayasu arteritis and Temporal (giant cell) arteritis
86
Medium- artery vasculitis includes________
Kawasaki disease which usually affects coronary arteritis
87
Medium to small artery vasculitis includes:
Thromboangiitis obliterans
Wegener granulomatosis
Polyarteritis nodosa
88
Temporal (Giant cell) Arteritis
Inflammation of arteries of the head and neck that typically affects people >50 y/o
S/s: unilateral; headache, scalp tenderness, jaw claudication
-may lead to unilateral blindness b/c of ischemic optic neuritis
Dx: biopsy of temporal artery
Tx: corticosteroids for visual symptoms to prevent blindness
89
What type of vasculitis is Polyarteritis Nodosa?
Vasculitis of the small and medium vessels that leads to glomerulonephritis, myocardial ischemia, peripheral neuropathy and seizures
90
Anesthesia Implications of Polyarteriti Nodosa
consider coexisting renal dz, cardiac dz, and HTN
Steroids likely beneficial
91
Which viral infections may be associated with Polyarteritis Nodosa?
Hep B, Hep C
92
What is a primary cause of death in patients with Polyarteritis Nodosa?
Renal failure
93
What are the treatment options for Polyarteritis Nodosa?
Steroids, cyclophosphamide, treating underlying cause
94
What are the symptoms of lower extremity chronic venous disease?
Mild: telangiectasias, varicose veins
Severe: Edema, skin changes, ulceration
95
Lower Extremity Chronic Venous Disease
Long standing venous reflux and dilation that effects 50% of the population
96
What is the diagnostic criteria for lower extremity chronic venous disease?
*Symptoms of leg pain, heaviness, fatigue
*Confirmed by ultrasounnd showing venous reflux
*Retrograde blood flow >0.5 seconds
97
What initial treatments are recommended for lower extremity chronic venous disease?
Leg elevation
exercise
weight loss
compression therapy
Skin barriers/emollients
Steroids
Wound Management
98
What are the methods of ablation treatment for lower extremity chronic venous disease?
* Thermal ablation w/laser
* Radiofrequency ablation
* Endovenous laser ablation
* Sclerotherapy
99
What are the contraindications for ablation treatment in lower extremity chronic venous disease?
* Pregnancy
* Thrombosis
* PAD
* Limited mobility
* Congenital venous abnormalities
100
Conservative Medical Treatment for Lower Extremity Chronic Venous Disease
*Diuretics
*Aspirin
*Antibiotics
*Prostacyclin analogues
*Zinc sulfate
101
What is the last resort for lower extremity chronic venous disease?
Surgical intervention is last resort
102
What are some risk factors for lower extremity chronic venous disease?
* Advanced age
* Family history
* Pregnancy
* Ligamentous laxity
* Previous venous thrombosis
* LE injuries
* Prolonged standing
* Obesity
* Smoking
* Sedentary lifestyle
* High estrogen levels
103
What has become the mainstay over open surgery with graft?
Endovascular stent
104
Symptoms of Aortic Dissection
severe sharp pain in posterior chest or back
105
What are the best ways to diagnose stable or unstable aortic dissections?
Stable: chest XR, CT, MRI, Angiogram
Unstable: Echo
106
Classes of Ascending Aortic Dissection
Stanford A, Debakey 1&2
107
Debakey I
Tear in the ascending aorta that propagates to the arch
108
Stanford A
Tear in the ascending aorta
109
Debakey II
Tear confined to the ascending aorta
110
What Classes are tears in the descending aorta?
Debakey III and Stanford B
111
If Aortic Arch is involved, ________is indicated
Surgical resection
112
What does surgery require for an aortic dissection repair?
*Cardiopulmonary bypass
*Profound hypothermia
*Period of circulatory arrest
113
Circulatory arrest at a body temp _____ for ________ can be tolerated by most pts
15-18°C
30-40 minutes
114
What is a major complication associated with aortic arch replacement?
Neurological deficit
-seen in 3-18% of patient
115
*What are the most catastrophic aortic disecctions?
Stanford A
DeBakey I &II
