Endovascular Cases Flashcards
What is a Debakey Type III?
Aortic dissection at the descending aorta only
What is a Debakey Type I?
Aortic dissection including both ascending and descending aorta
What is a Debakey Type II?
Aortic dissection involving only the ascending aorta
What is a Stanford A?
Aortic dissection involving the ascending aorta
What is a Stanford B?
Aortic dissection involving the descending aorta
What is EVAR?
Endovascular Aortic Repair
What is EVAAR?
Endovascular Abdominal Aortic Repair
What is TEVAR?
Thoracic Endovascular Aortic Repair
How much landing zone is needed for an aortic stent/graft to be placed?
1cm above and below
Why would the retroperitoneal approach be used?
If femoral vessels are small or heavily calcified
Which abd aortic pathologies are able to be endovascularly? Which Surgically?
Type A, B, C=endovascular
Type D, E=Surgical
Over 40% of TEVAR candidates have lesions covering which arterial branch?
Ostium of left subclavian artery
What must be done with a TEVAR candidate that has their left subclavian artery covered by the lesion?
Left Carotid-Subclavian Bypass procedure
Which procedure is completed first in a staged elephant trunk repair?
Stage 1= Total arch surgical replacement
Stage 2= Endovascular repair using trunk graft as proximal landing zone
Which Stage (1 or 2) of the Staged Elephant Trunk Procedure requires deep hypothermic circulatory arrest?
Stage 1
What are indications for and elective repair of an AAA?
Greater than 5.0cm or growing by more than 1 cm/year
What are indications for symptomatic aneurysms repair?
Repair all
What are indications for elective repair of a TAA?
Greater than 5.5cm or growing greater than 3mm/year
Can EVARs be done under MAC/sedation?
Patient must be able to lay supine for 1-2hrs without deep sedation d/t patient needing to hold breath for imaging
Other than general contraindications to neuraxial blockade, what specific contraindications are there for epidurals/spinals for EVAR?
- No need for TEE
- No need for MEP or SSEPs
- No need for COMPLETE motionless field during stent deployment.
What specific patients may be great candidates for central neuraxial blockade versus GETA?
Patients with terrible lung disease that may have issues coming off ventilator
What are 5 reasons to choose GETA for EVAR case?
- Complicated- fenestrated or branched endografts
- Planned use of TEE
- Planned hemodynamic manipulations to create motionless field
- Planned SSEP or MEP monitoring
- History of difficult airway.
Is EVAR considered high-risk surgery?
Yes; Patients should undergo functional testing consistent with ACC/AHA guidelines.
What is the biggest risk during planned or unplanned hemodynamic manipulations with EVAR?
Acute Kidney Injury
What are 4 reasons for AKI in EVAR cases?
- Hypoperfusion/hypotension
- Mechanical encroachment of stent graft on renal vessels
- Emboli to the renal arteries
- Contrast induced nephropathy
How often does contrast induced nephropathy occur?
2-10% of patients
What are four methods of reducing risk of AKI?
- Ensure perioperative euvolemia
- Maintain CO and BP
- Limit contrast dye
- Use Iso-osmolar/non ionic contrast dye
What 3 medications can be used with patients that have baseline kidney disease?
- N-Acetylcysteine
- Sodium Bicarbonate
- Statin Drugs
(also steroids)
What are 4 major causes of intra-operative hypotension/blood loss?
- Iliac artery rupture
- Accidental withdrawal of device
- Rupture of the aortic aneurysm
- Retroperitoneal bleeding
Why might an EVAR patient have a lactic acidosis?
- Secondary to reperfusion of lower extremities following decreased flow from cannulation
Why might the anesthesia provider be asked to induce Vfib?
To limit ejection and heart to remain still for valve deployment in TAVRs and work close to the aortic valve.
What pharmacologic treatment may the surgeon administer to treat vasospasm?
Nitroglycerin
How do you calculate Spinal Cord Perfusion Pressure (SCPP)?
SCPP= MAP - CSF Pressure
T/F: As CSF drainage increases through SA drain, SCPP will go down?
False; draining more CSF will decrease CSF pressure and therefore increase SCPP
What is the largest arterial blood supply to the spinal cord?
Artery of Adamkiewicz
Where does the Artery of Adamkiewicz arise from the aorta?
Typically T9-T12 (can arise from T5-L5).
Managemant of Paraplegia following TEVAR?
- Elevation of MAP >80mmHg
- Therapeutic CSF drainage
- Repeated neuro exam
- Avoid abrupt cessation of CSF drainage
What is post-implantation syndrome?
Early in the post-op period characterized by fever, leukocytosis, elevation of inflammatory mediators (CRP)
Describe the 5 endoleaks:
Type I: Leaking around graft Type II: Retrograde flow from other vessles Type III: Rupture or Mis-aligned Type IV: Pressure in graft Type V: Leaking through graft
T/F: Most trials show no benefit with EVAR compared to open in the short term; but long term EVAR is better?
False; Benefits in short term with EVAR, but by one year, they are equal
What did the DREAM trial show?
Dutch Randomized Endovascular Aneurysm Management trial showed 30 day mortality rate 1.2% EVAR and 4.6% Open
More equal after one year
What plays a huge role in why EVAR cases may do better inititally?
Patient selection is major factor
