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Principles II, Exam 1 > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

Thromboangitis obliterans

A

Chronic recurring, inflammatory, vascular occlusive disease of peripheral arteries and veins of the extremities

Less common cause of PVD,
Heavy smokers as young as 20-40 years old

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2
Q

Takayasu’s arteritis:

A
  • pulseless disease, infla disease, occluded 1 or more branches of the aortic arch

Less common cause of PVD

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3
Q

Common sites of atherosclerosis lesions

A

Coronary arteries
Carotid bifurcation
Abd aorta
Iliac and femoral arteries

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4
Q

What are some s/s of atherosclerosis

A 
Claudication
Pain
Skin ulceration
Gangrene
Impotence
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5
Q

What determines the extent of disability

A

Collateral blood flow

When demand > supply = ischemia: cramping, tiredness, pain, earnest occurs in limb

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6
Q

Medical treatment for atherosclerosis

A
  • Exercise, stop smoking, ASA, control of HTN and DM,
  • anti platelet therapy,
  • ADP receptor antagonists
  • Glycoprotein inhibitor
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7
Q

Surgical therapy

A 
Stent 
Angioplasty 
Enarterectomy 
Thrombectomy 
Bypass: aortofemoral, fem-pop, axil-fem
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8
Q

What is the primary objective of monitoring pt

A

Detection MI, high risk

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9
Q

Arterial pressure waveform

A
  1. Anacratic limb: initial upsweep: contractility, strong LV fun
  2. Dicrotic limb: downstroke: reflects SVR
  3. Dicrotic notch: closure AV and start of diastole
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10
Q

Most common aneurysm and position

A

AAA,

95% occur below the level of the renal artery

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11
Q

Normal size of the aorta

Aneurysm is defined when size…

A
  1. 2-2 cm

1. 5 times the diameter of normal vessel

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12
Q

What is the mortality rate of aneurysm

Elective vs emergency

A

Elective 2-6%
Emergency 40-88%

MI is responsible for 30-70% of all fatalities after AAA repair
Overall fatality of aneurysm rupture is 70-80%

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13
Q

Laplace law aneurysm application is

A

As radius increases, wall tension increases
Larger aneurysm = greater risk of rupture
T = PR or T = PR/2

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14
Q

Contra for aortic reconstruction

A 
Acute MI
Intractable angina
Severe pulmonary insufficiency
Chronic renal insufficiency
Life expectancy
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15
Q

What happens to blood proximal to clamp, supra celiac aorta clamp

A

Increased:

  • venous return: preload
  • intracranial blood volume
  • lung blood volume
  • blood volume and flow in muscles proximal to clamp
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16
Q

Shift of blood volume into splanchnic vasculature with infra celiac clamp

A

If splanchnic venous tone is high: Increased preload

If splanchnic venous tone is low: decreased venous return and preload

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17
Q

Aorta clamp on; what is happening?

A

Passive venous recoil distal to clamp
Increase catecholamines and other vasoconstrictors
Decreased venous return cause of vasoconstriction
Blood volume shifts proximally to clamp
Next depends when the clamp is placed

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18
Q

What does pathophysiology of aortic cross-clamping depends on?

A
  1. Level of the cross clamp: infra renal, higher - greater response
  2. Extent of CAD and myocardial function
  3. Degree of periaortic collateralization
  4. Blood volume and distribution
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19
Q

What happens proximally to clamp

A

Redistribution of blood volume

Everything increased except CO, which remains the same or decreases slightly

20
Q

What are the causes of reactive hyperemia?

A
  1. Transient vasodilation
  2. Release of adenine nucleotides
  3. Release of vasodepressor that acts as myocardial depressant and peripheral vasodilator - decreased pre/afterload: decreased CO
21
Q

Key points of declamping shock syndrome?

A

Hemodynamic instability
Restoring IVF b4 clamp release may help w/circulatory stability
Gradual release decrease the hemodynamic changes

22
Q 
What is released in response to tissue ischemia?
#1
A

Venous endothelian

23
Q

What is venous endothelian responsible for

A

Hemodynamic instability
Has positive inotropic effect on the heart
Vasoconstricting/dilating effects on blood vessels

24
Q

Arteriosclerosis

A
  • generalized inflammatory disorder of the arterial tree w/endothelial dysfunction
  • formation of plaque that obstruct the vessel lumen/ dec distal blood flow
    Plaque formation - Thrombosis - emboli - dec distal blood flow - weakening of the arterial wall - aneurysm
25
Q

Metabolic changes associated with aortic cross clamping

A
  1. Increase of plasma catecholamines: inc HR, myocardial O2 demand
  2. Acidosis: release-lactic, PG, thromboxone, cytokines
  3. Activation of renin angiotensin system
  4. Platelet and neutrophils sequestration: blood clotting/constriction
  5. Component activation
26
Q

What is mesenteric traction syndrome

S/S

A

Traction on mesenteric artery in order to expose aorta
Unknown cause
S/S: decreased B/P and SVR, inc HR and CO, facial flushing

27
Q

Renal preservation

A 
Prevent hypovolemia
Mannitol: 12.5g 20-30 min b4 clamping
Loop diuretics
Dopamine 3-5 mcq/kg/min
Fenoldopam: selective DA1 receptor agonist. No effect on alpha/beta
28
Q

Mannitol effects

A

May improve renal cortical flow during cross clamping
May reduce ischemia: induced renal vascular endothelial cell edema and vascular congestion
Acts ass scavenger for free radicals
Decreases renin secretion
Increases renal prostaglandin synthesis

29
Q

What to administer b4 aorta gets clamp

A

Heparin 100-200 units/kg or CPB 300 units/kg

SE: vasodilation, dec BP, anaphylactic reaction

30
Q

ACT
Normal
CPB
How long to wait b4 checking ACT after giving heparin

A

90-120 seconds
On CPB want ACT >480 sec
3-5 min and check ACT

Reverse with 1 mg protamine=100 units of heparin

31
Q

How to assure adequate fluid status? Renal protection, Doing what

A

Check: CO, UO, filling pressures

32
Q

Why 2D TEE after cross clamp release > 4 min hypotension

A

Hidden persistent bleeding
Miscalculated fluid/blood replacement
A rare allergic reaction to the graft/protamine
Inadequate metabolism of the citrate in a blood

33
Q

Problems of Juxtarenal aortic aneurysm repai

A
  • Renal failure
  • Paraplegia when cross clamping at or above the level of diaphgram
  • More pronounced hemodynamic changes, proximal aorta clamp
  • LV afterload increase more-closer clamp to heart- high risk for MI
34
Q

Renal cooling

A

Done if ischemic episode is >45 min

Flushing kidneys w/iced lytes containing heparin and glucose

35
Q

What is the SSEP and MEP used

A

SSEP: to identify spinal cord ischemia, primary dorsal column function (sensory)

MEP: info about the anterior spinal cord function (motor)

36
Q

Which aneurysm main goal is to cross clamp aorta ASAP

A

Ruptured aneurysm

37
Q

What is lumbar spinal cath placed for

What is the goal

A

Placed to monitor: spinal cord perfusion pressure = SCPP
SCPP = MAP - CVP (or CSF whichever is higher)
Keep > or equal to 30 mmHg to avoid paraplegia

The goal is to increase MAP and decrease CSF pressure

38
Q

What r the s/s of ruptured aneurysm

A

Abd discomfort
Pulsatile mass
Back pain
Hypotension/shock

39
Q

Who has the poorest prognosis with ruptured aneurysm

A

Pt that has Hypotension and hx of cardiac disease

94% mortality rate

40
Q

1 APACHE score

A

Good predictor of how pt will do

41
Q

EVAR - endovascular repair of AAA
What type of aneurysm
How is it reach,

A

Descending thoracic and AAA

Femoral artery-aorta- stent graft placed- under fluroscopic control

42
Q

Main disadvantage of EVAR

A

Endoleak: persistent blood flow and pressure between the graft and the aneurysm

43
Q

Advantages of EVAR

A

Hemodynamic stability, no clamping
Decreased: emboli, renal dysfunction, post op discomfort
Reduced stress response

44
Q

Do u give heparin b4 cath for EVAR procedure

And what dose

A

Yes, lower dose
50-100 units/kg
Keep pt warm

45
Q

Hypotension during EVAR reason

A

Always rule out that is not due to aortic rupture or Endoleak, talk to surgeon
May need to switch to open

Principles II, Exam 1 (8 decks)

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