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CV Perf Tech III > Aortic Surgery- Exam 2 > Flashcards

Aortic Surgery- Exam 2 Flashcards

1
Q

What is the goal of aortic surgery?

A

Enable aortic repair while limiting ischemic injury to the CNS

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2
Q

We utilize different perfusion strategies depending on what?

A

What portion of the aorta is affected

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3
Q

What are the 4 portions of the aorta?

A

Ascending
Arch
Thoracic
Descending

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4
Q

What are the two different types of aortic conditions?

A

Aneurysms

Dissections

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5
Q

Ascending Aorta

A

Begins at the AV annulus and extends to the proximal innominate artery

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6
Q

Transverse Arch

A

Where 3 brachiocephalic branches arise

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7
Q

How does the treatment for ascending and transverse arch compare?

A

Very similar

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8
Q

Descending Thoracic and Thoracoabdominal Aorta

A

Lies just beyond the subclavian to the aortoiliac bifurcation

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9
Q

Dissection

A

Occurs when blood penetrates the intima of the aorta; creates an expanding hematoma between medial layers; true lumen is not usually dilated/compressed by dissection

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10
Q

Are the branching vessels affected in a dissection?

A

May not be

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11
Q

Aneurysm

A

Dilation of all 3 layers

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12
Q

Incidence of Aortic Dissections

A

According to European Autopsy Study

Occurs in 3.2 dissections per 100,000 autopsies

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13
Q

What occurs in more deaths: Aortic Dissection or Aneurysm rupture?

A

Aortic dissection

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14
Q

Aortic Dissection risk factors

A

Hypertension (90% pts), advanced age (>60), male sex, Marfan’s Syndrome, Coarctation, bicuspid AV, pregnancy, toxins and diet

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15
Q

Marfan’s Disease

A

Connective Tissue disorder

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16
Q

Aortic Dissection Causes (Inciting Events)

A

Increased Physical Activity
Emotional Stress
Blunt Trauma
Can occur w/o any physical activity (i.e. cannulation for bypass)

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17
Q

Aortic Dissection Mechanism

A

Intimal Tear; presence of a weakened aortic wall; areas experiencing greatest mechanism shear forces, points where the aorta is fixed, there is increased shear stress applied to the aortic wall

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18
Q

What percent has intimal tear in ascending aorta?

A

61%

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19
Q

What percent has intimal tear in descending aorta?

A

24%

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20
Q

What percent has intimal tear in descending aorta; isthmus (distal to left subclavian)

A

16%

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21
Q

What percent has intimal tear in arch?

A

9%

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22
Q

What percent has intimal tear in abdominal?

A

3%

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23
Q

What percent has intimal tear in other areas?

A

1%

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24
Q

How fast does propagation occur?

A

Within seconds

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25
Q

What is propagation driven by?

A

Pulse pressure and ejection velocity

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26
Q

What may be involved in aortic dissections?

A

Origins of arteries; vessel occlusions can also occur due to compression by the false lumen

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27
Q

DeBakey Classification

A

3 types based upon location of intimal tear and which section of the aorta is involved; Type 1, 2, 3A, 3B

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28
Q

Debakey Classification: Type 1

A

Intimal Tear: Ascending Aorta

Dissection: All parts of the thoracic Aorta (ascending, arch, and descending)

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29
Q

DeBakey Classification: Type 2

A

Intimal Tear : Ascending Aorta
Dissection: Ascending Aorta only
stops before innominate artery

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30
Q

DeBakey classificaiton: Type 3A

A

Intimal Tear: Descending Aorta

Dissection: Descending Thoracic only distal to left subclavian, ends above diaphragm

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31
Q

DeBakey Classficiation: Type 3 B

A

Intimal Tear: Descending Aorta

Dissection: below diaphragm

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32
Q

Whats the “easier” classification system?

A

Stanford (Daily) Classficiation; Type A and Type B

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33
Q

Stanford (Daily) Classification: Type A

A

Ascending Aorta
Any involvement regardless of where tear is
regardless of how far it propagates; usually emergent/urgent cases more virulent course

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34
Q

Stanford (Daily) Classification: Type B

A

Distal Aorta

Any part of aorta distal to left subclavian

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35
Q

Prognosis for untreated ascending dissection

A

Dismal
2 day mortality- 50%
3 month mortality- 90%

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36
Q

What is the usual cause of death in aortic dissection?

A

Rupture of the false lumen into the pleural space or percardium

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37
Q

Lower incidence of death in what types of patients…

A

Debakey Type III

Stanford B

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38
Q

Other causes of death

A

Progressive heart failure (AV involvement)
MI (Coronary involvement)
Stroke (Occlusion of cerebral vessels)
Bowel Gangrene (Mesenteric artery occlusion)

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39
Q

Surgical Mortality of Aortic Dissections

A

3-24%
Depends on affected section of aorta
Aortic arch- highest mortality
Descending Thoracic- lowest mortality

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40
Q

What is the incidence of Thoracic Aneurysms? What percent of hwat types?

A 
European studies show 460/100,000 thoracic aneurysms
45% involved ascending aorta
10% involved arch
35% involved descending aorta
10% thoracoabdominal
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41
Q

Aneurysms Classification by shape

A

Fusiform

Saccular

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42
Q

Fusiform

A

entire circumference of the aortic wall

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43
Q

Saccular

A

Involves only part of the circumference of the aortic wall

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44
Q

Arch aneurysms are typically what shape?

A

saccular

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45
Q

What type of classification is used to classify thoracoabdominal aortic anuerysms?

A

Crawford Classification

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46
Q

Crawford Classificiation

A

used to describe the extent of aorta requiring replacement

Crawford Extents I-IV

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47
Q

Crawford Classificiation: Extent 1

A

involves most or all of the descending thoracic aorta and upper abdominal aorta

48
Q

Crawford Classification: Extent 2

A

Involves most or all of descending thoracic aorta and extends into infrarenal abdominal aorta

49
Q

Crawford Classification: Extent 3

A

Involves the distal 1/2 or less of descending thoracic aorta and varying portion of abdominal aorta

50
Q

Crawford Classification: Extend 4

A

involves most of all abdominal aorta

51
Q

Aneurysms: Natural Hx

A

Progessive dilation

52
Q

What fraction of aortic aneurysms rupture?

A

more than 1/2

53
Q

What is the untreated 5 year survival of the thoracoabdominal aortic aneurysm?

A

13-39%

54
Q

What are other complications of aneurysms?

A

Mycotic infection
Atheroembolisation
Dissection (Rare)

55
Q

What are some predictors of poor prognosis in aneurysm patients?

A

Larger size (less than 10 cm max transverse diameter)
Presence of other symptoms
Associated CV disease (CAD, MI, CVA)

56
Q

When do the majoriy of thoracic artery tears occur?

A

After a trauma; involve a deceleration injury (MVA)

57
Q

MVA

A

desceleration injury; large shear stress on points of aortic wall that are relatively immobile

58
Q

What does thoracic artery tear lead to?

A

Immediate exsanguination and death

10-15 % are lucky and make it to the hospital (maintain integrity of the adventitial covering of the aortic lumen)

59
Q

Where do most thoracic artery ruptures occur?

A

Most occur distal to the origin of the left subclavian artery; due to fixation at the point of the ligamentum arteriosum

60
Q

What is the 2nd most common site of a thoracic artery rupture

A

ascending aorta just distal to the aortic valve

61
Q

Aortic Dissection diagnosis

A

dramatic onset

62
Q

Aneurysm Diagnosis

A

asymptomatic until late in course

medical evaluation for unrelated problem or complication of aneurysm

63
Q

Trauma Rupture Diagnosis

A

if they surivve trauma

s/s similar to descending aortic aneurysm

64
Q

Indications for Surgery: Ascending Aorta Dissection

A

Acute Type A
Virulent course
high mortality

65
Q

Indications for Surgery: Ascending Aorta Aneurysm

A 
Persistent pain despite small aneurysm
AV involvement creating MI
angina
rapidly expanding
greater than 5- 5.5 cm diameter
66
Q

Indications for Surgery: Aortic Arch Dissection

A

acute, limited to arch (rare)

67
Q

Indications for Surgery: Aortic Arch Anuerysm

A

repiar of arch aneurysm is more complicated
carries increased morbidity and mortality
persistent symptoms
greater than 5.5-6 cm
progressive expansion

68
Q

Indications for Surgery: Descending Aorta Dissection

A 
Medical management in acute phase
failure to control hypertension medically
continued pain
enlargement on CSR, CT, Angio
Neurologic Deficit
Renal/ GI ischemia
69
Q

Indications for Surgery: Descending Aorta Aneurysm

A

Greater than 5-6 cm
Expanding
Leaking
Chronic, causing persistent pain

70
Q

Perfusion: Aortic Surgery Considerations

A 
Where is the aneurysm located?
Where do we need to cannulate?
Do we need to circ arrest?
Median sternotomy vs. Thoracotomy
Full CPB or Left heart bypass?
71
Q

Very proximal aneurysms limited to what regions?

A

Aortic root or ascending aorta

72
Q

CPB w/o Circ Arrest Cannulation

A

Ascending aorta or transverse aorta, and dual stage in RA or Bicaval

73
Q

Where is the XC in CPB w/o circ arrest

A

proximal to the innominate artery

74
Q

If patient is unstable prior to sternotomy, where do you cannulate?

A

Femoral to go on CPB prior to sternotomy

75
Q

CPB w/o Circ arrest LV/PA Vent adn CPG

A

Normal LV/PA vent

Normal cpg

76
Q

DHCA

A

bloodless field

uncluttered by clamps and cannulas

77
Q

Does DHCA abate cerebral metabolic demands?

A

doesn’t necessarily abate cerebral metabolic demands; significant cerebral metabolic activity occurs at temperatures at which DHCA is initiated; promotes brain ischemia; accumulation of metabolic wastes

78
Q

When did RCP gain popularity?

A

90s

79
Q

When was RCP first done? By who?

A

1980 by Milles and Oschner; treating massive air embolism

80
Q

When was RCP used as neuroprotection?

A

1990

81
Q

What are the benefits of RCP?

A

Homogeneous cerebral cooling
air bubble wash out
wash out of embolic debris
wash out of metabolic wastes
prevent cerebral blood cell micro aggregation
Delivery of oxygen and nutrients to the brain

82
Q

ACP

A

older tehcnique

maintained pre-DHCA jugular venous sats and cerebral oxygen extraction

83
Q

Circ Arrest: Monitor Temps

A

Nasopharyngeal/Bladder
Arterial
Venous
Water

84
Q

Circ Arrest: Monitor Brain

A

EEG- brain activity

Electrocerebral silence dictates adequate cerebral cooling

85
Q

Circ Arrest: Drugs

A

Mannitol (25g) and steroids
enhances cerebral protection
put in the pump prior to turning off the pump

86
Q

Circ Arrest: Cannulation

A

Axillary Cannulation is preferred
artery is usually exposed prior to sternotomy
after heparin is given- 8mm graft is sewn to the artery
cannula is placed in the 8mm graft

87
Q

Circ Arrest: Cannulation in an emergency

A

femoral artery is used; if its a dissection, make usre that the cannula is in the true lumen; venous cannula- RA, bicaval, femoral depends on need and access

88
Q

Circ Arrest case: Cooling

A

10 degree C drop in temperature- reduces rate of oxygen consumption by 50%; as temperature decreases metabolic demand decreases; pump flows can be reduced to a CI of 1.6-1.8 L/min/m2

89
Q

A 10 degree C decrease in temperature causes what percent increase in blood viscosity?

A

20-25%

90
Q

Circ Arrest: Hemodilution to a hematocrit less than what percent?

A

25%

91
Q

When doing a circ arrest case, how long do you keep cooling?

A

Keep cooling until EEG shows no cerebral electrical activity
Usually takes about 20-25 minutes
brain temp 18-20C
cool no lower than 15 C

92
Q

When not using an EEG, cool for how long?

A

At least 25 minutes to a target core temp of 18-20 C

93
Q

At EEG silence, give what drug?

A

Pentobarbital

Circulate for 3 minutes

94
Q

What position is a patient put in during a circ arrest case?

A

Trendelenburg position

95
Q

Why would the head be packed in ice in a circ arrest case?

A

Facilitate Surface cooling

96
Q

ACP is at how many ml/kg/min?

A

10 ml/kg/min

97
Q

When the aorta is opened, you could get bleed back from what?

A

L Common Carotid and L Subclavian obscure field view; cardiotomy suction in distal arch; possible use of balloon occluder in both vessels

98
Q

Circ Arrest Case: End of gRaft is sewn where?

A

Sewn to proximal descending thoracic aorta, transverse arch or distal ascending aorta; attach head vessels (island, branched graft)

99
Q

Off pump: Want systolic BP of what?

A

100-120 mmHg

100
Q

Off pump: MAP

A

70-90 mmHg

101
Q

Off pump: HR

A

60-80 BPM

102
Q

Off pump: CI

A

2.0-2.5 L/min/m2

103
Q

Complications of Aortic Surgery and DHCA

A 
Air Emboli
clots 
LV dysfunction
MI (reimplanting coronaries)
renal failure
respiratory failure 
coagulopathy
hemorrhage
104
Q

Other procedures of Aortic Conditions

A

Endovascular REpair

Left Heart Bypass

105
Q

When was an endovascular repair 1st done?

A

1991 on abdominal aortic aneurysm

106
Q

TEVAR

A

Thoracic Endovascular aortic repiar

107
Q

Endovascular Repair required proximal “landing zone” of what lenght?

A

15mm

108
Q

TEVAR Con

A

Side branches- possibility of occluding a vessel that branches off the aorta

109
Q

TEVAR Considerations

A

Aortic Tortuosity, calcification, atherosclerosis

110
Q

TEVAR Advantages

A 
reduces mortality
reduces morbidity
less blood loss
quicker recovery
hemodynamic stability
pulmonary and cardiac comorbidities that may have not made them a candidate for open surgeries, allow them to have this option
111
Q

TEVAR Complications

A

Conversion to open procedure (aortic rupture/dissection, malposition causing visceral ischemia)
bleeding
endoleak (blood flows back into the aneurysmal sac after the endovascular graft is placed; usually observe and hope it spontaneously resolves)
stroke
paraplegia
contrast nephropathy

112
Q

Left Heart Bypass

A

shunt around the aneurysm/dissection; used on descending legions

113
Q

Left Heart Bypass: ECC

A 
tubling 
centrifugal pump
noreservoir
n H/E
no bubble trap
exclusing those help minimize the heparinization required
114
Q

Who gives volume in left heart bypass?

A

Anesthesia

115
Q

What does connective tissue do?

A

Provides strength and support to tendons, ligaments, cartilage, blood vessel walls and heart valves

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