Ex 4: 1 Apr Vascular Disease Assessment Flashcards
What is an aortic aneurysm?
Aortic aneurysm is a dilation in the wall of the vessel leading to an increase in greater than 50% of the diameter
Symptoms are due to compression of surrounding structures since there is no pain sensation in the vessel itself.
What is the general treatment approach for small aortic aneurysms?
Initially treated medically to prevent growth, including blood pressure management and lifestyle changes
- Surgery is generally indicated when the aneurysm approaches 5.5 cm in diameter or the aneurysm diameter begins increasing by 10+mm/yr
What is the mortality rate associated with aortic aneurysm rupture?
75% mortality rate
This makes it an extremely dangerous situation requiring monitoring and surgical intervention.
What are the two types of aortic aneurysms?
Saccular aneurysms (berry-shaped bulge) and fusiform aneurysms (uniform circumferential dilation)
Both types involve a dilation greater than 50% of the vessel diameter.
What imaging techniques are used to diagnose aortic aneurysms?
CT, MRI, angiogram, echocardiogram, and Doppler echocardiogram
These methods provide clear pictures of the aneurysm’s size and structure.
What is aortic dissection?
A tear in the intimal layer of the vessel causing blood to seep into the medial layer
It is different from a rupture as it is still relatively contained.
What are the types of aortic dissections based on the Stanford classification?
Type A: must involve ascending aorta and can occur in succession with another location in the aorta.
- Type A dissections require emergency surgery.
Type B: does NOT involve ascending aorta.
What are the symptoms of aortic dissection?
Sharp, severe pain in the posterior chest or back
This pain is a telltale sign and may require immediate medical attention.
What is the general mortality increase per hour for untreated aortic dissection?
1 to 2% increase per hour
Overall mortality is about 25% to 50%.
What is the typical treatment for Type A aortic dissections?
Emergency surgery is required, often involving replacement of the ascending aorta
Surgical procedures may include aortic valve replacement and cardiopulmonary bypass.
What are common risk factors for aortic dissection?
- Hypertension
- Atherosclerosis
- Family history
- Cocaine use
- Inflammatory diseases
- Genetic disorders like Marfan syndrome
Other factors include trauma or iatrogenic causes such as cardiac catheterization.
What is the typical long-term survival rate for patients treated medically for Type B aortic dissection?
60% to 80% at six years, about 40% to 50% at ten years
Medical management is indicated for uncomplicated Type B dissections.
Fill in the blank: An aortic aneurysm is generally treated surgically when it reaches _______ cm in diameter.
Other surgical indications are family history of dissection and aneurysm growth of >___mm/year
5.5
10
True or False: Aortic dissections can be classified using both Stanford and DeBakey classifications.
True
- We love to add layers to the confusion :)
What are the 3 classifications of DeBakey? This is a tricky one…
- Type I: **Originates in the ascending aorta **and propagates to the aortic arch
- Type II: Originates in and is limited to the ascending aorta.
- Type III: Originates in the descending aorta and rarely extends proximally, but will extend distally.
What is the treatment for uncomplicated Type B aortic dissections?
Medical management with close monitoring and blood pressure control
Patients may be treated with beta blockers and vasodilators.
What is the most common complication associated with surgical treatment for aortic dissection?
Neurological deficits
These can arise from cardiopulmonary bypass procedures.
What is an iatrogenic cause of aortic dissection?
Cardiac catheterizations
Iatrogenic causes refer to conditions caused by medical treatment or procedures.
What are common populations associated with aortic dissection?
Men and pregnant women in their third trimester
These groups are at higher risk for developing aortic dissection.
Define an aneurysm.
Dilation of all three layers of a blood vessel.
Define a dissection.
Blood that enters into the medial layer of the vessel.
What are predisposing factors for an aneurysm?
- Hypertension
- Atherosclerosis
- Older age
- Male gender
- Family history
- Previous dissection
What symptoms are associated with an aortic dissection?
Severe, sharp posterior chest pain.
How is an aortic aneurysm typically diagnosed?
Imaging techniques such as chest X-ray, Echo, CT, MRI, angiography.
What is the triad of symptoms for a rupturing aneurysm?
- Extreme hypotension
- Back pain
- Pulsatile abdominal mass
What is retroperitoneal tamponade?
A protective clot formation in the peritoneum that can prevent massive blood loss, especially in instances of dissection.
- Note: Volume resuscitation may be delayed until the rupture is surgically controlled. Maintaining a lower BP reduces risk of losing retroperitoneal tamponade, further bleeding, hypotension, and death
What are the four primary causes of mortality related to thoracic aorta surgery?
- Myocardial Infarction (MI)
- Respiratory failure
- Renal failure
- Stroke
What preoperative evaluations are important for patients undergoing thoracic aorta surgery?
- Cardiac evaluation tests (stress test, echocardiogram)
- Pulmonary function tests
- Renal function tests
What is anterior spinal artery syndrome?
Ischemia due to lack of blood flow to the anterior spinal artery, affecting motor function.
What are common causes of anterior spinal artery syndrome?
- Aortic aneurysm
- Aortic dissections
- Atherosclerosis
- Trauma
What is the main symptom of a CVA?
Sudden onset neurological deficits.
What are the two types of CVA?
- Ischemic
- Hemorrhagic
List of inherited and modifiable risk factors for stroke
- Sorry the exhaustive list is too much to ask about so have a picture instead.
What is a TIA? What makes them exceptionally dangerous, even if they resolve with relatively little issue?
Transient ischemic attack, a temporary, self-limited cerebral ischemia.
- Symptoms usually resolve within 24 hours but patients now have a 10x greater risk of subsequent stroke
What diagnostic tests can be used for carotid disease?
- Angiograms: can dx vascular occlusion
- CT and MRI
- Transcranial Doppler ultrasound to monitor occlusion in real-time
- Carotid doppler and ultrasound: to identify bruits and quantify the degree of stenosis
What is the recommended treatment window for TPA administration after a CVA?
Within four and a half hours of symptom onset.
What is a carotid endarterectomy? At what stage of stenosis is this warranted?
A surgical treatment to remove plaque from the carotid artery.
- lumen diameter 1.5mm or >70% blockage
What is the significance of maintaining a higher MAP during carotid surgery?
To ensure adequate cerebral perfusion and collateral blood flow.
What is the risk associated with carotid stenting?
Risk of micro mobilization leading to a CVA.
What ongoing medical therapy is recommended after treatment for a CVA?
- Antiplatelet medications
- Blood pressure control
- Cholesterol medications
- Lifestyle modifications
What is the acceptable blood pressure range to optimize cerebral perfusion during surgery?
Maintain mean arterial pressure (MAP) on the higher side of normal
- Know your patient’s baseline vitals
This helps ensure adequate cerebral perfusion pressure (CPP) by keeping MAP elevated while considering intracranial pressure (ICP)
What is the formula for calculating cerebral perfusion pressure (CPP)?
CPP = MAP - ICP
This formula is crucial for understanding cerebral blood flow dynamics during surgery.
What should be monitored to ensure optimal cerebral oxygenation/perfusion during surgery?
Cerebral oximetry
What is the main clinical dilemma regarding patients with carotid artery disease?
They often have severe coronary artery disease, requiring staged interventions
The most compromised area takes priority for intervention.
What physiologic factors affect cerebral oxygen delivery?
- CBF
- MAP
- CO
- Sa02
- HGB
- PaC02
How does PaCO2 influence cerebral blood flow?
Lower levels cause vasoconstriction, higher levels cause vasodilation
Even small changes in PaCO2 can significantly affect vessel size and blood flow.
What is the Ankle-Brachial Index (ABI) and its significance?
ABI < 0.9 indicates peripheral artery disease
- It is calculated as the ratio of systolic blood pressure at the ankle to that at the brachial artery. So (Ankle SBP)/(Brachial Artery SBP)
What are common symptoms of peripheral artery disease?
- Intermittent claudication
- Resting extremity pain
- Decreased pulses
- Subcutaneous atrophy
- Hair loss
- Coolness
- Cyanosis
- Relief w/hanging LE over side of bed (↑hydrostatic pressure)
Symptoms often worsen with exercise due to inadequate perfusion.
What diagnostic tools are used for peripheral artery disease?
- Doppler US: provides a pulse volume waveform identifies arterial stenosis
- Duplex US: can identify areas of plaque formation & calcification
- Transcutaneous oximetry: can assess the severity of tissue ischemia
- MRI w/contrast angiography: used to guide endovascular intervention or surgical bypass
These tools help assess arterial stenosis and tissue ischemia.
What is the primary treatment for severe peripheral artery disease?
Revascularization of the affected vessel by:
* Surgical reconstruction- arterial bypass procedure
* Endovascular repair-transluminal angioplasty or stent placement
This is indicated in cases of severe claudication or ischemia.
What causes acute peripheral artery occlusion?
Typically due to embolism, often cardiogenic in nature
Common sources include left atrial or left ventricular thrombosis.
What are symptoms of acute peripheral artery occlusion?
- Limb ischemia
- Pain
- Paresthesias
- Weakness
- Decreased periphreal pulses
- Cool skin
- Color changes distal to the occlusion
These symptoms indicate reduced blood flow to the affected limb.
What is subclavian steal syndrome?
A condition where blood flow to the brain stem is compromised due to occlusion of the subclavian artery
This can lead to neurological symptoms and is often diagnosed through arteriogram.
What is a common cause of stenosis leading to subclavian steal syndrome?
Atherosclerosis
Other risk factors include a history of aortic surgery and Takayasu arteritis.
What is the treatment for subclavian steal syndrome?
Arteriotomy to clear out the artery
- Arteriotomy is a surgical procedure that involves making an incision in an artery.
This restores proper perfusion to the affected areas.
What symptoms indicate that a patient may have subclavian steal syndrome?
Limb ischemia that worsens with activity
* Syncope
* Vertigo
* Ataxia
* Hemiplegia
* Ipsilateral arm ischemia
Effected arm SBP may be up to 20mmhg lower
Bruit over SCA
Increased oxygen requirements during limb activity lead to ischemia if blood flow is obstructed.
What complications may arise from decreased perfusion in patients with subclavian steal syndrome?
Dizziness, syncope, and decreased radial pulses
These symptoms result from reduced blood flow to the brain and limbs.
What imaging technique is mentioned for visualizing stenosis in subclavian steal syndrome?
Angiography
Angiograms can help visualize blood flow and identify areas of stenosis.
What is Raynaud’s phenomenon?
Episodic vasospasm of the digits
This condition leads to poor blood flow, particularly in fingers, often triggered by cold exposure.
What are the common causes of Raynaud’s phenomenon?
Rheumatic diseases, medications, and endocrine disorders
Conditions like scleroderma and lupus can trigger Raynaud’s.
What is the primary treatment for Raynaud’s phenomenon? Additional treatments?
Calcium channel blockers
- Protection from the cold and alpha-blockers
T/F: Raynaud’s affects women more than men.
T
___’s Triad is a list of 3 symptoms associated with DVTs. What are they?
Venous stasis (lack of venous bloodflow), vascular (endothelial) injury, and hypercoagulability
What are common risk factors for developing DVT? Added picture will list them all so have fun!
- Age over 40
- Recent surgery
- Prolonged immobility
- Cancer
These factors increase the likelihood of venous stasis and thrombosis.
What diagnostic tools are used for DVT?
Doppler U/S, venography, and impedance plethysmography
These imaging techniques help confirm the presence of deep vein thrombosis.
What prophylactic measures are taken to prevent DVT in surgical patients?
- Compression stockings
- SCD devices
- Heparin
These interventions aim to enhance venous return and reduce clot formation.
What is the first-line treatment for DVT?
Anticoagulation therapy with Warfarin, Heparin, LMWH(Lovenox)
Heparin or low molecular weight heparin is often used initially.
What is systemic vasculitis? What are the different types?
A group of vascular inflammatory diseases characterized by the size of the vessels at the primary site of the abnormality
* Large-artery vasculitis:Takayasu arteritis,Temporal (or giant cell) arteritis
* Medium-artery vasculitis: Kawasaki disease, which usually effects the coronary arteries
* Medium tosmall-artery vasculitis: Thromboangiitis obliterans, Wegener granulomatosis, Polyarteritis nodosa
What are the symptoms of temporal arteritis?
- Unilateral headache
- Scalp tenderness
- Jaw claudication
Opthalmic Arterial branches may lead to ischemic optic neuritis and unilateral blindness
How is temporal arteritis diagnosed?
Temporal artery biopsy
Biopsy shows inflammation in the artery in 90% of patients.
What is thromboangiitis obliterans also known as?
Buerger’s disease
- This condition is characterized by inflammation of small and medium vessels, primarily seen in smokers.
- Autoimmune response triggered by nicotine
What are the diagnostic criteria for Buerger’s disease? (5)
Tobacco use is most predisposing factor
* h/o smoking
* onset before 50
* infrapopliteal arterial occlusive dz
* upper limb involvement
* Absence of risks factors for atherosclerosis (outside of tobacco)
Diagnosis is confirmed with biopsy of vascular lesions. and is most often seen in men <45y/o
What is the most effective treatment for thromboangiitis obliterans?
Smoking cessation followed by surgical revascularization
- No effective pharmacological intervention
Stopping smoking can significantly improve vascular health in affected individuals.
What is the most effective treatment for Raynaud’s disease?
Smoking cessation
This treatment helps re-establish perfusion in the vessels
What surgical procedure may be necessary for severe ischemia in Buerger’s or Raynaud’s disease?
Surgical revascularization
Required if smoking cessation is not adhered to
What anesthesia implications should be considered for patients with Burger’s or Raynaud’s disease?
- Meticulous positioning and padding
- Avoid cold; Warm the room and use warming devices
- Prefer non-invasive BP and conservative line placement
Avoid cold and keep patients warm
What is Polyarteritis nodosa?
A vasculitis of small and medium vessels
- Inflammation can lead to glomerulonephritis, myocardial ischemia, peripheral neuropathy and seizures!
What are common associations with Polyarteritis nodosa?
Hepatitis B and C, hairy cell leukemia
Renal disease is a significant concern
What is the primary treatment for Polyarteritis nodosa?
Corticosteroids and cyclophosphamide
Treat underlying causes like cancer if present
What are the anesthetic implications for patients with Polyarteritis nodosa?
Attention to coexisting renal or cardiac disease and and HTN are critical.
- Chronic steroid administration will probably be beneficial.
May require stress dose steroids during surgery
What is chronic venous insufficiency?
Long-standing venous reflux and dilation in lower extremities
Affects about half the population
What are the risk factors for lower extremity chronic venous disease?…it is a lot
- Advanced age
- Family history
- Pregnancy
- Ligamentous laicity
- Previous venous thrombosis
- Lower extremity injuries
- Prolonged standing
- Obesity
- Smoking
- Sedentary lifestyle
- High estrogen levels
Birth control pills increase risk
Signs and symptoms for chronic venous insufficiency?
Ranges from mild-severe
- Mild sx: telangiectasias, varicose veins
- Severe sx: edema, skin changes, ulceration
What is the primary diagnostic tool for chronic venous insufficiency?
Ultrasound: Confirmed by showing venous reflux with retrograde blood flow > 0.5 seconds
Other diagnostic criteria: Symptoms of leg pain, heaviness, fatigue
What are initial treatment measures for chronic venous insufficiency?
- Leg elevation
- Avoid prolonged standing
- Exercise
- Weight loss
- Compression stockings
Conservative management is usually sufficient
What treatments may be used for significant skin ulceration in chronic venous insufficiency?
- Skin barriers
- Emollients
- Steroids
- Wound management
- Diuretics
- Aspirin
- Antibiotics
- Prostacyclin analogues
- Zinc sulphate
If management fails, ablation may be performed
What are some methods for chronic venous insuf. ablation?
- Thermal ablation w/laser
- Radiofrequency ablation
- Endovenous laser ablation
- Sclerotherapy
What are some contraindications for chronic venous insuf. ablation?
- Pregnancy
- Thrombosis
- PAD
- Limited mobility
- Congenital venous abnormalities
What is the last resort treatment for chronic venous insufficiency?
Open surgical intervention
Includes procedures like saphenous vein inversion and ligation
