B3 L40: Vascular Surgery Flashcards
1
Q
What is peripheral vascular disease (PVD)?
A
Obstruction of the large arteries that supply blood to the peripheries (outside of the heart and brain). PVD ranges from asymptomatic disease through to limb threatening reduced blood supply.
2
Q
What is the prevalence of PVD of people over the age of 55?
A
10-25% of people
3
Q
Does the risk of PVD increase/decrease with age? Or is it unaffected?
A
Increases with age
4
Q
PVD is more prevalent is ___(men/women).
A
Men
5
Q
70-80% of people with PVD are _____.
A
asymptomatic- this means it is highly underdiagnosed
6
Q
About half of patients with PVD have symptomatic ____ or _____ vascular disease. This means it doesn’t happen in isolation
A
coronary; cerebral
7
Q
What are the 11 causes of PVD?
A
- Atherosclerosis
- Thromboembolism
- Aneurysm
- Inflammatory processes
- Smoking
- Diabetes Mellitus
- Dyslipidemia (high cholesterol)
- Hypertension
- Obesity
- Stroke/CV disease
- Family history of vascular disease
8
Q
What is atherosclerosis?
A
Thickening of the artery wall as a result of the accumulation of calcium and fatty materials (cholesterol)
9
Q
What does the thickening of the artery wall in atherosclerosis lead to?
A
Leads to reduced elasticity of the artery walls – allows less blood to travel through and increases blood pressure
10
Q
What happens when plaque is deposited in the artery in atherosclerosis?
A
Plaque deposits can expand and cause blockage of the artery or lead to a thrombus formation, or can break away as an embolus and occlude smaller downstream branches
11
Q
What is an aneurysm?
A
Localised blood filled balloon-like bulge (weakness) in the wall of a blood vessel (leading to a possible rupture) – Can be the starting point for a thrombus
12
Q
What is the problem with an aneurysm?
A
Can lead to a possible rupture
13
Q
How do inflammatory processes cause PVD?
A
leading to stenosis through swelling of the arterial wall
14
Q
Why is smoking such a high risk factor and cause of PVD?
A
Smoking causes changes in and damage to the endothelial lining of blood vessels (which are permanent and irreversible), which leads to atherosclerosis
15
Q
Is smoking a high risk factor/cause for PVD?
A
Over 80% of patients with PVD are current or exsmokers
16
Q
Smoking results in earlier onset of symptoms and the severity of PVD _____ (increases/decreases) with the number of cigarettes smoked and number of _____.
A
increases; years
17
Q
Why is Diabetes Mellitus a risk factor/cause of PVD?
A
2-4 times increased risk of PVD by causing endothelial and smooth muscle cell dysfunction (damage) in peripheral arteries
18
Q
______ account for up to 70% of non-traumatic amputations performed
A
Diabetics
19
Q
A known diabetic who smokes runs an approximately 30% risk of ______ within 5 years
A
amputation
20
Q
What does diabetes cause (neurally)?
A
Peripheral neuropathy
21
Q
What a characteristic of peripheral neuropathy?
A
lack of sensation to feet
(eg. won’t feel injuries –> infection and lack of healing –> possible amputation)
22
Q
What is Dyslipidemia?
A
high cholesterol levels
23
Q
What do people have with chronic PVD?
A
long standing symptoms
24
Q
What is claudication?
A
pain with walking -not getting enough blood to muscles that help with walking
25
What are 4 symptoms of patients with chronic PVD?
1. Pain with walking secondary to decreased circulation
2. Relief occurs after ceasing activity (muscles no longer need the increased blood flow)
3. Cramping, aching, fatigue, numbness
4. May involve one or more of the buttock, thigh or calf muscles, depending on location of obstruction
26
Why do some patients with chronic PVD not complain of claudication?
If activity limited by comorbidities
27
What is a progression of chronic PVD with claudication?
Ongoing, constant pain at rest
28
What does constant pain at rest represent in a patient with chronic PVD?
A significant reduction in circulation and usually involves the most distal aspect of the lower extremity
29
Patients will chronic PVD with constant pain at rest will report a relief in symptoms with \_\_\_\_\_\_\_. Give an example
dependency (gravity facilitates circulation)
30
Patients will chronic PVD with constant pain at rest will report aggravating factors of?
elevation
31
Usually, the pain in patients with chronic PVD is quite \_\_\_\_\_(mild/severe) and ____ (will/will not) wake during the night (affect sleep).
severe; will
32
What is the classification of chronic PVD? How many categories?
Category 0: Asymptomatic
Category 1: Mild claudication
Category 2: Moderate claudication
Category 3: Severe claudication
Category 4: Rest pain
Category 5: Minor tissue loss; Ischemic ulceration not exceeding ulcer of the digits of the foot
Category 6: Major tissue loss; Severe ischemic ulcers or frank gangrene
33
What is category 0 for chronic PVD?
Asymptomatic
34
What is category 1 for chronic PVD?
Mild claudication
35
What is category 2 for chronic PVD?
Moderate claudication
36
What is category 3 for chronic PVD?
Severe claudication
37
What is category 4 for chronic PVD?
Rest pain
38
What is category 5 for chronic PVD?
Minor tissue loss; Ischemic ulceration not exceeding ulcer of the digits of the foot
39
What is category 6 for chronic PVD?
Major tissue loss; Severe ischemic ulcers or frank gangrene
40
What are 6 characteristics of PVD?
1. Atrophy of calf muscle (vicious cycle- no walking as much due to pain --\> makes it worse)
2. Loss of hair growth over lower leg and foot
3. Thickening of nails (need podiatrist to cut)
4. Decreased subcutaneous tissue
5. Shiny fragile skin
6. Dependent rubor
41
What are 4 ways to diagnose PVD?
1. Ankle-Brachial Pressure Index (ABPI/ABI)
2. Exercise testing
3. Lower limb Doppler ultrasound
4. Angiography/CT/MRI
42
How is the Ankle-Brachial Pressure Index (ABPI/ABI) used to diagnose PVD?
When the blood pressure readings in the ankles are lower than that in the arms, it would be suspected that there are blockages in the arteries delivering blood from the heart to the ankle
* Normal ABI range is 1.00 to 1.40.
* PVD = ABI ≤ 0.90
43
How is exercise used to diagnoses PVD?
Walking or treadmill test --\> pain
44
What is 6 conservative management techniques for PVD?
Done by management of lifestyle
1. Smoking cessation
2. Diabetic management (control sugar levels)
3. Management of HTN (hypertension- reduce stress)
4. Management of cholesterol
5. Antiplatelet therapy
6. Exercise
45
Supervised exercise programs have been recommended as first-line therapies for the treatment of ____ in patients with PVD
claudication
46
In particular, walking to near \_\_\_\_\_\_\_has been found to improve \_\_\_\_\_\_, theorised to be due to the development of the \_\_\_\_\_\_\_.
maximal pain; intermittent claudication; collateral blood supply
47
What are the 3 main aims of exercise programs for people with PVD?
1. to reduce limb symptoms (pain)
2. to improve exercise capacity and prevent or lessen physical disability (more fit; more blood to the legs)
3. to reduce the occurrence of cardiovascular events
48
At PAH, our Vascular Rehabilitation is a ____ week program consisting of _____ hour exercise sessions once per week run by a Registered Nurse and Physiotherapist • Warm up, exercise station circuit, cool down • Treadmill, Stationary bike, Recumbent bike, Rowing machine, Step-ups, Hand weights, Arm windjammer. What is the most important exercise in this program?
12; 1 Treadmill (claudication)
49
With vascular rehabilitation at the PAH, what is the main outcome measure?
Progressing Treadmill Test (goes through stages of walking speed and incline of treadmill will increase)
50
Patients are encouraged to walk to\_\_\_\_\_\_ out of 10 pain before stopping. In this study, what are the 2 things that are recorded
6-7
1. Records the Claudication Pain Time (CPT)
2. Maximum Walking Time (MWT)
51
The PVD patient has Fortnightly Education Sessions using the _____ approach
MDT
52
What things is the vascular registered nurse in charge of for a PVD patient?
Peripheral Arterial Disease, Causes Symptoms and Treatment
53
What things is the physiotherapist in charge of for a PVD patient?
PAD and Exercise Therapy
54
What things is the HTN CNC in charge of for a PVD patient?
Hypertension Management
55
What things is the dietician in charge of for a PVD patient?
Healthy Eating/Cholesterol Control
56
What things is the pharmacist in charge of for a PVD patient?
Vascular Medicines
57
When is surgical intervention used for a PVD patient?
When conservative management is not enough
58
Choice of surgery depends on the ____ of symptoms, associated \_\_\_\_\_\_, technical considerations and evidence-based outcomes
severity; comorbidities
59
Ideally is it better to try a more ______ approach of surgery first e.g. endovascular treatments first. ______ usually reserved for patients for whom these have failed or are not an option
conservative; Open surgery
60
What is an endovascular surgery?
Minimally invasive surgery designed to access regions of the body via major blood vessels
61
How is an endovascular surgery done?
Involves the introduction of a catheter percutaneously into a large blood vessel
62
What is an angioplasty?
The technique of mechanically widening narrowed or obstructed arteries by inflating a balloon (which is inserted into the artery)
63
What are the 3 steps to an angioplasty?
1. An empty and collapsed balloon on a guide wire, known as a balloon catheter, is passed into the narrowed locations and then inflated
2. This forces expansion of the plaque deposits and the surrounding muscular wall, opening up the blood vessel for improved blood flow
3. The balloon is then deflated and withdrawn. A stent may or may not be inserted at the time of ballooning to ensure the vessel remains open
64
Post-op for an angioplasty, patients generally need to ______ for at least ____ hours. Furthermore, they need to avoid ________ for at least \_\_\_\_\_\_.
rest in bed; 4; strenuous physical activity; a week
65
Post angioplasty op, one must monitor puncture site for any signs of ________ or ______ development
bleeding; haematoma
66
What are the 4 types of Supra-inguinal open surgery (Inflow operations)?
1. Aorto-bifemoral bypass graft
2. Axillo-bifemoral bypass graft
3. Iliofemoral bypass – unilateral or femoral-femoral crossover
4. Femoral endarterectomy and profundaplasty
67
When are Supra-inguinal open surgery (Inflow operations) used?
Used for aorto-iliac disease
68
What is the function of the Supra-inguinal open surgery (Inflow operations)?
Inflow operations restore blood flow to the top of the leg
69
When is a Aorto-bifemoral bypass graft used?
disease of the infrarenal aorta and common iliac arteries
70
What are 5 indications to undergo a Aorto-bifemoral bypass graft?
1. Severe claudication symptoms
2. Non healing ulcers of the extremities
3. Aortic aneurysms
4. Acute abdominal aortic occlusion
5. Critical limb ischaemia limb threatening
71
What are the 3 steps to how a Aorto-bifemoral bypass graft is done?
1. An incision is made in the abdomen and bilateral groin.
2. Blood is redirected through a graft made of synthetic material, sewn above and below the diseased artery Recreates the normal anatomy of the aorta and femoral arteries – most successful but most traumatic
3. Recreates the normal anatomy of the aorta and femoral arteries – most successful but most traumatic
72
Is an artificial or a natural graft used in a Aorto-bifemoral bypass? Why?
The artificial blood vessel is used rather than natural graft due to the large blood vessels involved – durable and cope well with the high arterial blood flow
73
What is the benefit of the aorto-bifemoral bypass surgery?
Recreates the normal anatomy of the aorta and femoral arteries – most successful
74
What is the disadvantage of the aorto-bifemoral bypass surgery?
Most traumatic surgery
75
How is the axillo-bifemoral bypass graft done?
The axillary artery in the shoulder is connected to the femoral arteries using an artificial graft.
76
When is the axillo-bifemorla bypass graft done instead of the aorto-bifemoral bypass?
The stress of this operation on the heart is less as it avoids opening the abdomen- for patients who are not as strong (May be performed for infected aortic grafts or more high risk patients)
77
While the axillo-bifemorla bypass graft done instead of the aorto-bifemoral bypass has it put less stress on the heart, what is the disadvantage of this surgery?
is more prone to complications, such as blockage and infection, as it is narrower and more superficial
78
What is the femoral-femoral cross-over? How is it done?
A graft originates from a normal femoral artery in the groin on one leg and takes blood to the femoral artery in the groin of the opposite leg
79
How is an ilio-femoral bypass done?
The graft originates from the iliac arteries in the pelvis and takes blood to the femoral arteries in the groin
80
When is an ilio-femoral bypass done?
For cases of isolated iliac or proximal common femoral artery occlusive disease where the aorta and the proximal ipsilateral common iliac artery are free of severe occlusive disease
81
What is the purpose of a femoral endarterectomy?
Open procedure to remove the atherosclerotic plaque or build-up in the lining of an artery (common femoral artery, deep femoral artery) scrap plaque out of artery- clear out build up (may return)
82
What is the benefit of the femoral endarterectomy?
Avoid risk of infection associated with prosthetic material
83
Just as atherosclerosis develops in the lower extremity arteries, it can deposit in other arteries in the body and _______ blood flow – coronary (CABG) or carotid
restrict
84
What is the purpose of the carotid endarterectomy?
reduces the risk of stroke by correcting stenosis in the carotid artery
85
When is a carotid endarterectomy needed?
Pieces of plaque can break off and travel up the internal carotid into the brain
86
When pieces of plaque can break off and travel up the internal carotid into the brain, what is the risk?
blocks- high risk of occulusions (ischemia stroke)
87
What is the function of an infra-inguinal open surgery (Outflow operations)?
Bypasses a blocked artery below the knee
88
In infra-inguinal open surgery (Outflow operations), the _____ vein is used as the donor conduit. Why not use an artificial vein?
saphenous Better not to use artificial materials which don’t function as well with the lower blood flow in smaller arteries
89
What are the 3 types of infra-inguinal open surgery (Outflow operations)?
1. Femoro-popliteal bypass graft
2. Femoro-tibial bypass graft
3. Femoro-crural bypass graft
90
Depending on the site of \_\_\_\_\_, a combination of procedures could be performed (eg endarterectomy + fem-pop bypass)
occlusion
91
What does a Femoro-popliteal bypass graft look like? What is the clinical presentation of a patient? What are they not able to usually do?
Leg is straight (extended) and externally rotated
Unable to flex (due to the staples which go down the length of the leg)
92
What does Femoro-tibial bypass graft look like?
93
After bypass graft surgery, what are 4 important things to do?
Pulses will be checked frequently to monitor blood flow to the limb • Also will monitor colour, warmth, pain and movement • Wound will be observed for any signs of infection or dehiscence • Anticoagulants
94
After bypass graft surgery, what are 4 long term effects?
Graft patency – one study had an 84% limb salvage rate and a 78% primary graft patency rate at 21 months of follow-up. Prosthetic grafts carry a primary 3-year patency rate of 39% with a 25% risk of amputation within 3 years • Limb salvage rates are lower among patients with insulin-dependent diabetes. Amputation rate after femoro-distal bypass remains high, with adverse events occurring after approximately 38% of femoro-popliteal procedures and nearly 50% of femoro-distal bypasses. The main predictors of a poor outcome reportedly were diabetes and chronic renal failure (poor survival rates) • The overall survival rate for patients with lower extremity arterial occlusive disease is approximately 50% over 10 years. For patients who require bypass surgery, the survival rate drops to approximately 50% over 5 years
95
What are the 3 important lifestyle management factors (disease modifications)?
1. Exercise (Vascular Rehab) (even if it is just walking exercise)
2. Foot care
* skin checks, well fitting shoes (poorly fitted shoes = small blister --\> poor healing --\> amputation), podiatrist management
3. Smoking cessation, BSL control, HTN management
96
What is an Abdominal Aortic Aneurysm (AAA)?
a localised “ballooning” of the abdominal aorta.
97
Most AAAs can occur \_\_\_\_(supra/infra/para)renally but can occur \_\_\_\_(supra/infra/para)renally or \_\_\_\_(supra/infra/para)renally
infra; para; supra
98
What is the major complication with an AAA?
rupture which can be life threatening
99
What are 3 treatment options for AAA?
1. Open repair
2. Endovascular (EVAR)
3. Elective (reach the point of high risk of rupture) vs emergency (once ruptured)
100
What are the 4 steps of how a AAA open surgery repair is done?
1. Large incision – from breastbone to navel
2. Aneurysm is repaired by the use of a long tube shaped graft
3. Graft is sutured to the aorta
4. Aorta is clamped off during the repair – no blood to the entire abdomen and both legs
101
After an open AAA surgery repair, there is _____ (significant/small) recovery time – ICU post op, ____ (extended/shortered) hospital stay. Pain \_\_\_\_(can/won't) be an issue
significant; extended; can
102
How is a EVAR (Endovascular Aortic Repair) done?
Stent graft inserted through the femoral artery and advanced up to the aortic aneurysm
103
A EVAR (Endovascular Aortic Repair) is \_\_\_\_\_\_(minimally/highly) invasive and _____ (is/is not)feasible for all AAA
minimally; is not
104
When are EVAR (Endovascular Aortic Repair) needed?
Appropriate for aneurysms that begin below the renal arteries – need adequate length of aorta to attach the endograft
105
In the EVAR, there is _____ (more/less) risk of mortality, \_\_\_\_\_\_(increased/decreased) length of stay, _____ (more/less) risk of complications
less; decreased; less
106
When should pre-operative assessment be done for vascular surgeries?
Previous level of mobility (aids, distance- claudication limitation), home set up, pre-existing respiratory/cardiovascular compromise, motivation, education
107
What are 3 post operative assessments for vascular surgeries
1. Circulation
2. Chest
3. Mobility
108
What are 3 treatments for vascular surgeries?
1. Circulatory exercises
2. Chest therapy as per identified problems
3. Mobility starts with rollator, progressed to prior level
4. Home Exercise Program (possible ROM exercises)
5. Education and advice re lifestyle changes
109
Post vascular surgeries, don’t want vascular patients “\_\_\_\_". Why?
hopping increase risk of injury to their unaffected limb or falling
110
Vascular compromised patients may have reduced _______ due to their comorbidities.
exercise tolerance
111
What are 3 main things to reinforce in vascular patients?
Reinforce
1. Foot care
2. exercise
3. lifestyle changes
112
What is important to remember with the other leg in vascular patients?
Consider effect of taking a graft on the unaffected leg- changes in function (ROM, strengh)
113
What are the 6 P's associated with an acute arterial occlusion?
1. Pain
2. Pallor
3. Pulselessness
4. Paraesthesia (loss of sensation)
5. Paralysis
6. Poikilothermy (cool)
114
Symptoms in an acute arterial occlusion can occur within minutes to hours and are associated with a sudden dramatic decrease in \_\_\_\_.
perfusion
115
What are the 4 causes of critical limb ischaemia?
1. Failed bypass graft – infection, thrombosis
2. Thrombosis of native vessels due to progressive atherosclerosis
3. Embolism from the heart -AF (arterial fibrillation)/MI
4. Injury – compartment syndrome (due to compression)
116
Revascularisation \_\_\_\_\_(well/poorly) tolerated in frail patient with critical limb ischaemia.
poorly
117
What are 2 co-morbidities of a critical limb ischiaemia?
1. severe dementia
2. dense hemiplegia
118
What are 3 factors to consider in the selection of the level of amputation?
1. Healing potential (how high must be amputated for good recovery- to receive good blood flow)
2. Rehabilitation potential
3. Prosthetic considerations
119
The aim with amputation to preserve the ________ wherever possible. Why?
knee joint Easier for prosthetic walking/transfers
120
Foot amputations are most commonly performed in _____ with foot wounds because of their susceptibility to\_\_\_\_\_ of the bone
diabetics; infection
121
When will foot amputations only heal?
If blood flow is restored might do arterial surgery to help with blood flow before amputation
122
With a foot amputation, often open amputation with ______ primary closure +/- VAC dressing. May use ____ reconstructive techniques eg flaps
delayed; plastic
123
Multiple operative procedures depending on the ____ of surrounding tissue
recovery
124
Post operatively (foot amputation), what kind of weight bearing?
Non-WB
125
What is the function of the foot bootie post foot amputation surgery?
Work closely with orthotists to offload areas of ulceration/wound and protect foot
126
What is the benefit of the transtibial amputation?
better functional outcome
127
What is the disadvantage of the transtibial amputation? Why?
Poorer healing- further down the leg (blood flow)
128
What is the benefit of the transfemoral amputation?
Better healing- closer (more proximal) = blood flow
129
What is the disadvantage of the transfemoral amputation? Why?
poorer functional recovery (energy output is higher = a lot harder to move around)
130
What are the 3 patient status characteristics on day 1 post vascular surgery (unilateral amputation)?
1. Drain
2. PCA
3. Stump heavily bandaged
131
What are the equipment on day 1 post vascular surgery (unilateral amputation)?
Triflo, slideboard, w/chair +/- stump support, cushion
132
What are the assessment on day 1 post vascular surgery (unilateral amputation)?
Check:
* -operation report and Hb
Assess:
* cardiorespiratory
* musculo-skeletal function
133
What are the 5 treatments on day 1 post vascular surgery (unilateral amputation)?
1. Breathing and circulation exercises
2. Static quads, glutes and upper limb exercises
3. SOOB in a w/chair, if Hb stable, normotensive and pain controlled
4. D/W with N/S and aim to T/F into shower chair, likely it will be 2 X A ( 2 assisted transfer)
5. If sitting in W/C day 1 unlikely to self-propel due to attachments
134
What are the 3 patient status characteristics on day 2 post vascular surgery (unilateral amputation)?
1. Drain removed
2. PCA down
3. bandage debulked
135
What are the equipment on day 2 post vascular surgery (unilateral amputation)?
Triflo, slideboard, wheelchair +/- stump support, cushion
136
What are the assessment on day 2 post vascular surgery (unilateral amputation)?
Assess
* cardiorespiratory
* musculo-skeletal function
137
What are the 4 treatments on day 2 post vascular surgery (unilateral amputation)?
1. Continue with respiratory and circulatory exercises
2. Progress strengthening and provide handout as indicated
3. SOOB for first time OR progress transfer as able
4. Commence W/C skills as able
138
What should happen day 3 post vascular surgery (unilateral amputation)?
commence gym session and progress exercises to standing balance and strengthening in parallel bars (hips strengthening (squatting); quad strengthening (of unaffected side))
139
What should happen day 4 onwards post vascular surgery (unilateral amputation)?
Continue as for day 3 increasing repetitions with exercises and aiming for supervision/independence for transfers
140
Patients may be referred for ______ or be _______ home from the ward - wheelchair trials, equipment prescription, home visit/set up
rehabilitation; discharged
141
What should happen post vascular surgery (biilateral amputation)?
Will have 2 x drains in situ day 1, lose a lot of blood and generally it is very difficult to have independent sitting balance on an air mattress.
142
What should happen day 1 post vascular surgery (biilateral amputation)?
pt remains RIB
143
What should happen day 2 post vascular surgery (biilateral amputation)?
review sitting out in W/C and/or shower chair via hoist
144
What should happen day 3 onwards post vascular surgery (biilateral amputation)?
Take to gym and work on sitting balance / slideboard transfers on more solid surface
145
What are 7 other vascular surgeries?
1. Varicose Vein
2. Ist rib resection
3. Embolectomy (removed blood clots)
4. UL thrombectomy (slit down- reduce pressure)
5. Traumatic vascular injury repairs/embolization
6. Fasciotomies
7. Wound debridements +/- SSG
