Week 3 Vascular Surgery

Question 1

What is the primary etiology of vasculature pathologies?

Answer 1

Atherosclerosis

Question 2

Which artery is usually spared the effects of generalized atherosclerosis?

Answer 2

Internal mammary artery (ITA)

Question 3

Which comorbidities are closely linked to the development of atherosclerosis?

7

Answer 3

• Smoking
• DM
• Dyslipidemia
• Increase Triglycerides
• HTN
• OBCT
• Family hx

Question 4

What is the leading cause of mortality @ the time of vascular surgery?

Answer 4

CAD

Question 5

What is the pre-dominant cause of perioperative MI?

Answer 5

Demand ischemia

Question 6

What is the biggest contributor to demand ischema?

Answer 6

HR

Question 7

What major organ co-morbidies may be present preoperatively in a vascular patient?

Answer 7

• Chronic Renal Failure
• Malignant HTN

Question 8

What lab value indicates increased perioperative risk for AKI?

Answer 8

Creatinine >2mg/dL

Question 9

What 5 aortic lesion types require surgical repair?

Answer 9

Aortic:
* Dissection
* Aneurysm
* Occlusion
* Trauma
* Coarctation

Question 10

Type I DeBakey involves which parts of the Aorta?

Answer 10

Ascending Aorta -> Descending Aorta

Question 11

Type II DeBakey involves which parts of the Aorta?

Answer 11

Confined to the Ascending Aorta

Question 12

Type IIIa DeBakey involves which parts of the Aorta?

Answer 12

Confined to the Descending Thoracic Aorta

Question 13

Type IIIb DeBakey involves which parts of the Aorta?

Answer 13

Descending Thoracic Aorta -> Abdominal Aorta

Question 14

When is surgical correction required for an Ao. aneurysm?

Answer 14

5 - 5.5 cm or Unstable

Question 15

How will blood pressure manifest during an open Ao. aneurysm repair while cross clamped?

2

Answer 15

• HTN above clamp
• HoTN/No flow below

Question 16

What is the largest of the Radicular arteries?

Answer 16

Great Radicular Artery or Artery of Adamkiewicz

Question 17

What does the Artery of Adamkiewics (aka GRA) supply?

Answer 17

Major blood supply to lower 2/3s of the spinal cord

Question 18

What consideration regarding the GRA/Artery of Adamkiewics is important to know during Aortic repair surgery?

Answer 18

Susceptible to ischemia during high Ao. cross clamp

Question 19

About what level does blood supply arise from for the GRA/Artery of Adamkiewics?

Answer 19

T9-T12 in 75% of cases

Question 20

When should you tell your pt undergoing a CEA to hold their Aspirin?

Answer 20

You don’t, Aspirin should be continued through the perioperative period

Question 21

What extra monitoring/lines are appropriate additions to standard monitoring/lines?

Answer 21

• A-line
• 2 - 16g PIVs
• CVL only w/ hx of HF, recent MI, or poor IV access

Question 22

What needs to be collected/performed during a CEA pre-op?

4

Answer 22

• HR
• BP
• EKG
• Continue ASA/BP meds

Question 23

What interventions might be done to mitigate the hemodynamic changes from reperfusion syndrome post-cross clamp removal?

7

Answer 23

• Decrease Volatile agents
• Decrease Vasodilators
• Increase Fluids
• Increase Vasopressors
• Reapply x-clamp
• Mannitol
• NaHCO3

Question 24

Heparin dose required for cross-clamping but no CPBP?

Answer 24

50-100 units/kg

Miller’s says just 100

Question 25

What Blood pressure target during carotid x-clamp protects against what effect?

Answer 25

within 10-20% or greater of pre-operative Blood pressure * Post-op cognitive dysfunction | Nagelbutt pg. 607/ Miller's 1860

Question 26

The surgeon is about to x-clamp a high Ao. aneurysm, what medications will be used in preparation, why?

Answer 26

NTG or SNP * To control increase BP after clamp

Question 27

What are some neuromonitoring modalities used during a CEA? | 5

Answer 27

* EEG * SSEP * Carotid stump pressure * Transcranial doppler * Cerebral Oximetry

Question 28

What kind of drugs are ideal to control hemodynamic changes during CEA?

Answer 28

Short acting drugs

Question 29

What short acting drugs can be used to manipulate hemodynamics during CEA? | 6

Answer 29

* Esmolol * Phenylephrine * NTG * SNP * Nicardipine * Clevidipine | Miller's 1860

Question 30

What is the main goal for open Ao. Arch aneurysm repair?

Answer 30

Maintain end organ perfusion

Question 31

How might you monitor/improve end organ perfusion? | 4

Answer 31

* Invasive BP, PA catheter, TEE * UOP * ABGs -> resuscitation based on base deficit * Administer blood

Question 32

What are some indications for the placement of a spinal drain? | 6

Answer 32

* Emergency Surgery * Ao. Dissection * Ao. Rupture * Prior abdominal surgery * Hypogastric artery occlusion * Hx of renal dysfunction

Question 33

What are some of the perioperative risks of morbidity/mortality as they relate to CEA?

Answer 33

* Myocardial ischemia * Cerebral ischemia * Rough/slow emergence

Question 34

Goals to limit the risks of morbidity/mortality during CEA? | 4

Answer 34

* Minimize myocardial work * Optimize cerebral perfusion * Ensure CV stability * Rapid/smooth emergence

Question 35

What are some post-op complications of CEA? | 8

Answer 35

* Hemodynamic instability * MI/ischemia * Cerebral hyperperfusion syndrome * Stroke * RLN/SLN injury * Hematoma * Tension Pneumo * Carotid occlusion

Question 36

What are some preoperative things you want to get done for an Ao. dissection case? | 5

Answer 36

* Have a butt-ton of blood ready * Large bore IV access/Rapid infusers * A-line distal/proximal to x-clamp * DL ETT * Neuromonitoring

Question 37

Ao. Aneurysm vs. Dissection?

Answer 37

* Aneurysm: Involves all three layers of arterial wall (Tunica intima, media, adventia) * Dissection: Tear of the intima permitting longitudinal false blood passage

Question 38

Hemodynamic changes associated w/ x-clamp? | 8

Answer 38

* Increase ABP above/Decrease ABP below clamp * increase LV wall tension * increase PAOP * increase CVP * increase Coronary blood flow * decrease EF * decrease CO * decrease Renal blood flow