Abdominal Aortic Reconstruction

Question 1

what are 6 significant risk factors for post-op cardiac events?

Answer 1

• high risk surgery
• ischemic heart disease
• creatinine >2.0 mg/dl
• hx TIA or CVA
• type I DM
• hx CHF

Question 2

how many risk factors make a PT considered “elevated risk”?

Answer 2

2 or more

Question 3

what would indicate an ECG prior to a surgery?

Answer 3

any heart surgery, especially if pre-excisting structural heart disease.
*not for low risk surgery

Question 4

when would surgery require an echo (TEE) in the pre-op assessment?

Answer 4

• PTs with dyspnea

- PTs with previous LV dysfunction documented over a year ago

Question 5

what are considered “active cardiac conditions”?

Answer 5

• recent MI
• decompensated heart failure
• significant arrhythmias
• severe valvular disease

Question 6

when is a CABG indicated?

Answer 6

• stable angina w
• L main stenosis
• 3 vessel CAD
• 2 vessel CAD with LAD stenosis and EF

Question 7

how long should you delay an elective surgery after a balloon angioplasty?

Answer 7

14 days

Question 8

B-blocker use (Metoprolol) peri-op increased the risk for what?

Answer 8

stroke

• 4.3x preop metoprolol
• 3.3x intraop metoprolol

Question 9

B-blockers shown to reduce the rate of acute cardiac events for who?

Answer 9

PTs with CAD undergoing high risk surgery

Question 10

should you continue B-blockers if the PT is already on them peri-op?

Answer 10

yes

Question 11

how should B-blockers be managed after surgery?

Answer 11

by clinical circumstances

*independent of when BB started

Question 12

who may need a beta blocker pre-op who isn’t already on one?

Answer 12

intermediate or high risk MI on preop testing PTs

*should not be started day of surgery

Question 13

should statins be continued for PTs taking them?

Answer 13

yes, for noncardiac cases

Question 14

when would it be reasonable to initiate statin treatment on a PT?

Answer 14

• undergoing vascular surgery

- elevated-risk procedures

Question 15

ACE inhibitors or ARBs prior to surgery?

Answer 15

typically no, reasonable to restart them as soon as clinically feasible tho

Question 16

what monitors/access should we have for an AAR?

Answer 16

always
- ASA standard
- large IV
- a-line
sometimes
- CVL (good LV fx)
- PA cath (poor LV fx)
- TEE (poor LV fx and cardiac DX)

Question 17

for PTs undergoing aortic aneurysm repair, are fluid requirements greater or less?

Answer 17

greater

Question 18

renal blood flow is reduced with AAR clamping, for how long after unclamping?

Answer 18

1 hour, monitor urine output

*may need to use mannitol or furosemide

Question 19

what would you see with anterior spinal cord eschemia?

Answer 19

• loss of motor function

- loss of pain and temp sensation

Question 20

what would you see with posterior spinal cord eschemia?

Answer 20

• loss of proprioception and fine touch

Question 21

what are some considerations for open thoracic aneurysm repair?

Answer 21

• ascending aneurysms require cardiac bypass
• axilo-fem bypass for descending TAA
• keep CSF less than 10 mmHg
• steroids to protect spinal cord
• evoked potential monitor of spinal cord
• double lumen tube

Question 22

how much does an asymptomatic bruit/stenosis increase stroke risk for gen. surgery?

Answer 22

it doesn’t

Question 23

what is the carotid shunt during a CEA for?

Answer 23

allows cerebral blood flow during clamp.

*risk of emboli or distal dissection

Question 24

what does hyperperfusion syndrom look like?

Answer 24

• ipsilateral headache
• seizures
• focal neurologic signs

Question 25

when should you have high and low perfusion during AAR?

Answer 25

high perfusion before and during cross clamp

- low perfusion after unclamping

Question 26

what should you look for postoperatively?

Answer 26

• hypotension
• neck hematoma
• hyperperfusion syndrome

Question 27

what are risk factors for hyperperfusion syndrome?

Answer 27

• severe ICA stenosis
• hypertension
• contralateral ICA stenosis