Anesthesia for Vascular Surgery - Quiz 4 Flashcards by Donny Le

For pts w/ PVD & PAD, how must the MAP change in order to perfuse vital organs?

MAP must Increase

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Why are ART lines recommended for pts w/ PVD & PAD?

Hypotension, even for a little, can cause Ischemia

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What are the Major Risk Factors for Abdominal Aortic Aneurysms?

Smoking

Old Age

Men > Women

White > Black

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How are AAAs diagnosed?

Computed Tomography Angiography (CTA)

Pulsatile Abdominal Mass

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When is Surgical Intervention recommended for AAAs?

> 5.5 cm

4.5 w/ >0.5 cm growth in 6 months

Ruptured AAA

Symptomatic AAA

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How much do AAAs expand each year?

4mm / year

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In regards to AAAs, the Wall Tension is _____ proportional to Vessel Radius & Pressure, and ______ proportional to Wall Thickness.

In regards to AAAs, the Wall Tension is Directly proportional to Vessel Radius & Pressure, and Indirectly proportional to Wall Thickness.

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Which Artery is this?

Right Coronary Artery

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What are Contraindications to Elective AAA Repair?

Intractable Angina

Recent MI

Severe Pulm. Dysfunction

Chronic Renal Insufficiency

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What is the most common and preferred site of Abdominal Aortic Aneurysms?

Infrarenal

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What meds should be given to patients prior to AAA repair to optimize Myocardial Oxygen Supply & Demand?

B-Blockers

Statins

Fluid Load

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Which EKG leads should be used for AAA repairs?

Lead II - Arrythmias

Lead V₅ - ST Changes

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How is Blood Pressure affected by Aortic Cross Clamping?

↑BP above Clamp

↓BP below Clamp

↑Afterload

↑SVR

↑MAP

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What are pts w/ Poor LV function at risk for with Cross Clamping?

CHF

↑Afterload = ↑LV Wall Tension & O₂ Demand

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Which Artery is this?

Right (Acute) Marginal Artery

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What is the main factor that causes Cardiac Instability & Depression during Cross Clamping?

Release of Archidonic Acid

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Aside from Arachidonic Acid, what other substances are released during Cross Clamping?

Cytokines

Prostaglandins

Nitric Oxide

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What happens to the Heart w/ an Increase in Thomboxane A2 production?

↓Contractility

↓Cardiac Ouptut

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What are symptoms of Mesenteric Traction Syndrome from Cross Clamping?

Hypotension

Tachycardia

↑Cardiac Output

Facial Flushing

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Which sites of cross clamp have a higher risk for Acute Kidney Injury?

Suprenal & Juxtarenal - 80% renal blood flow reduction

(40% w/ Infrarenal)

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What can happen if a Suprarenal Cross Clamp is in place over 30 minutes?

Post-Op Renal Failure

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What meds should be avoided to prevent AKI from Cross Clamping?

NSAIDs

Gentamicin

Neomycin

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Which arteries supply 20% of Spinal Cord blood flow to the Dorsal/Sensory portion?

Posterior Artery x 2

Posterolateral Arteries x 2

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Which artery is this?

Left Coronary Artery

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Which artery supplies 80% of the Spinal Cord blood flow to the Motor Portion?

Anterior Spinal Artery

Damage to which artery causes Spinal Cord Ischemia?

Greater Radicular Artery / Adamkiewicz - tranverse blood flow to spinal cord

What are ways to minimize risk of Spinal Cord Ischemia?

CSF Drainage Mild Hypothermia Keep SBP \> 120 mmHg thru Post Op Day 2

What are the Hemodynamic Changes associated w/ Cross Clamp Release?

↓Contractility & Cardiac Output ↓CVP & Venous Return ↓SVR, Preload & Afterload

What causes the Transient Vasodilation w/ Cross Clamp Release?

Release of built up Anaerobic Metabolites Release of Adenine Tissue Hypoxia

When used, what are the advantages of an Epidural for Open AAA Repair?

↓Preload & Afterload Preserves Cardiac Oxygen ↓Stress Response ↓Pulmonary Problems Post-Op Pain Control

When used, what are the Disadvantages of an Epidural for Open AAA Repair?

Anticoagulation Hematoma Risk Severe Hypotension w/ Blood Loss & Cross Clamp Release

How are fluids managed w/ an Open AAA Repair?

Replace Third Space Loss @ 10mL/kg/hr Keep Urine Output @ 1mL/kg/hr Cell Saver

Which type of Aortic Aneurysm is at the Renal Artery Level & Spares the Renal Artery Orifice?

Juxtarenal Aneurysm

Which type of Aneurysm includes at least one Renal Artery & possibly Visceral Vessels?

Suprarenal Aneurysm

Which artery is this?

Circumflex Artery

What are the symptoms of a Ruptured Aortic Aneurysm?

Severe Abdominal/Back Pain Altered Level of Consciousness d/t Hypotension Pulsatile Abdominal Mass

Which type of Aortic Aneurysm carry the highest risk for Rupture?

Thoracic Aortic Aneurysm Most commonly caused by Atherosclerosis

What are the different types of Thoracic Aortic Aneurysms?

* **Fusiform** - Spindle Shape w/ Aorta Dilation * **Saccular** - Spherical & Limited to one Segment of Vessel Wall

What are the symptoms of a Thoracic Aortic Aneurysm?

Pain Stridor Cough Hoarseness d/t Left RLN Impingement

What equipment is needed for a Thoracic Aortic Aneurysm repair located in the Ascending Aorta?

Cardiopulmonary Bypass

Which type of Aortic Aneurysm is this?

Type II Distal to Left Subclavian Artery & Below Renal Arteries

Which type of Aortic Aneurysm is this?

Type V Below 6th ICS to just above Renal Arteries

Which type of Aoritc Aneursym is this?

Type I Distal to Left Subclavian Artery & Above Renal Arteries

Which type of Aortic Aneursym is this?

Type IV From 13th ICS to Iliac Bifurcation (Entire Abdominal Aorta)

Which type of Aortic Aneurysm is this?

Type III From 6th ICS to Renal Arteries

Which artery is this?

Left (Obtuse) Marginal Artery

Where should the A-Line be placed if the Aneurysm is in the Thoracic Region or Distal Aortic Arch?

Right Radial

What are Lumbar Intracthecal Catheters used for in regards to Thoracic Aneurysm Repair?

Monitoring CSF Pressure & Drainage SSEP MEP

How Spinal Cord Perfusion pressure measured?

Spinal Cord Perfusion Pressure = MAP - CSF Pressure

How does Cross Clamping affect CSF Pressure

Increases CSF Pressure & Decreases Arterial Pressure distally

What is the Goal CSF Pressure during Cross Clamping?

CSF Pressure \< 10 mmHg

What is an Aortic Dissection?

Spont. tear of vessel w/ blood passing along a false lumen HTN worsens it

What is a DeBakey Type I Aortic Dissection?

From Ascending Aorta to Aortic Arch & often into Descending Aorta

What is a DeBakey Type II Aortic Dissection?

Confined to Ascending Aorta

What is a DeBakey Type III Aortic Dissection?

From Descending Aorta just distal to Left Subclavian Artery & Extends Distally

What is a Stanford Type A Aortic Dissection?

Involves Ascending Aorta

What is a Stanford Type B Aortic Dissection?

Dissections that do NOT involve Ascending Aorta

Which artery is this?

Left Anterior Descending Artery

How is an Endovascular Aortic Aneurysm Repair done?

Guidewire thu Bilateral Fem Arteries to the Aneurysm, then Sheath over guidewire and Deploy Stent from Sheath

What are complications to an EVAR?

Failed Deployment Microemolization Stent Migration Aortic Perf Hematoma Endoleak Graft Tear, Stenosis, Thrombosis Access Artery Damage Infection Kidney Injury d/t Contrast Radiation Exposure

What is a Type I Endoleak?

Attachment Site Leaks Fix w/ Graft Extension, Second Graft or Open Repair

What is a Type II Endoleak?

Branch Leaks Monitor or Fix w/ Lap Clip or Embolization

What is a Type III Endoleak?

Graft Defect (Tear, Disconnect) Fix w/ Second Graft or Open Repair

What is a Type IV Endoleak?

Graft Porosity or Suture Holes Fix w/ Second Graft or Open Repair

When are Carotid Endarterectomies (CEA) indicated?

Carotid Stenosis \> 70%

What are symptoms of Carotid Stenosis?

TIA/Stroke Carotid Bruit Monocular Blindness

What factors increase Morbidity risk for CEAs?

Stroke Hx Hyperglycemia Old Age Multiple Comorbidities Ulcerative Lesion

Which artery is this?

Diagonal Arteries

How is Cerebral Pefusion Pressure measured?

CPP = MAP - ICP

At what MAP is Cerebral Autoregulation constant?

MAP 60 - 160 mmHg

What causes Cerebral Steal?

Hypercarbia -\> cerebral vasodilation --\> Ischemia

When would Ischemia be a concern when measuring Cerebral Oximetry?

A decrease \> 20% during CEA

What should the pts MAP be during Carotid Cross Clamping?

20% or more w/ a goal SBP \> 160 mmHg After Clamp Removal: SBP \< 140 mmHg

If a CEA is done under regional, which nerve would you want to block?

Deep & Superficial Cervical Plexus Block for Cranial Nerves II-IV

Which volatile agent should not be used for CEAs?

Avoid N₂O - Pneumocephalus Risk

What are the Post Op CEA Complications?

**HTN** - most common Cerebral Hyperperfusion Syndrome (Headache, Vision Problems, LOC, Seizures) Hemodynamic Instability Stroke Resp Insufficiency Cardiac Ischemia PTX

What are the complications of Carotid Stenting?

**Stroke** - Most Common MI Bradycardia & Hypotension Horner's Syndrome Cerebral Hyperperfusion Carotid Dissection Hemorrhage