Exam 3 Vascular Disease [Jia] Flashcards
1
Q
What are the 3 main arterial pathologies?
A
- Aneurysms
- Dissections
- Occlusions
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2
Q
______ is a dilation of all 3 layers of artery, leading to a >50% increase in diameter
A
Aortic aneurysm
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3
Q
Why do sx occur with aortic aneurysm? When is surgery indicated?
Mortality rate?
A
- Sx may be due to compression of surrounding structures
- Initially treated medically
- Surgery indicated @ >5.5 cm diameter
- Aortic aneurysm rupture is associated with a 75% mortality rate
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4
Q
What are the 2 types of aortic aneurysm
A
- Fusiform
- Saccular
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5
Q
______ Uniform dilation along entire circumference of arterial
wall
A
Fusiform
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6
Q
_____ berry-shaped bulge to one side
A
Saccular
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7
Q
What diagostic tools are used for aortic aneurysm? for suspected dissections?
A
- CT, MRI, CXR, Angiogram, Echocardiogram
- In suspected dissection, doppler echocardiogram is fastest/safest measure of obtaining a diagnosis of aneurysm
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8
Q
Aortic aneurysm treatments include:
A
- Medical management to ↓expansion rate
- Manage BP, Cholesterol, stop smoking
- Avoid strenuous exercise, stimulants, stress
- Regular monitoring for progression
- Surgery indicated if >5.5 cm, growth >10mm/yr, family h/o dissection
- Endovascular stent repair has become a mainstay over open surgery w/graft
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9
Q
_______ Tear in intimal layer of the vessel, causingblood to enter the medial layer
A
Dissection
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10
Q
____ catastrophic, requiresemergent surgical intervention
A
- Ascending dissection:
- Stanford A, Debakey 1 & 2
- Mortality increases by 1-2% per hr
- Overall mortality 27-58%
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11
Q
What are the sx for Ascending dissection
A
Severe sharp pain in posterior chest or back
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12
Q
Diagnosis methods forStable and unstable aortic dissections
A
- Stable = CT, CXR, MRI, Angiogram
- Unstable=Echocardiogram
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13
Q
What are the 2 ways to classify Aortic Aneurysm Dissection
A
- Stanford Class A, B
- DeBakey Class 1,2,3
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14
Q
Stanford A Dissection
A
- Ascending aorta: should be considered candidates for surgery
- Aortic Arch dissection: resection of the aortic arch isindicated.
- Procedure 1: ascending aorta & aortic valve replacement w/a composite graft
- Procedure 2: replacement of the ascending aorta and resuspension of the aortic valve
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15
Q
Surgery for type A dissection involves?
A
- requires cardiopulmonary bypass, profound hypothermia, and aperiod of circulatoryarrest
- a period of circulatory arrest of 30-40 minutes at a bodytemperature of 15-18°C can be tolerated by mostpatients
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16
Q
What is the major complications associated with replacement of theaorticarch
A
- Neurologic deficits
- Occur in 3-18% of pts, and it appears that selective antegrade cerebral perfusiondecreases but does notcompletely eliminatethe morbidity and mortality associated with thisprocedure
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17
Q
What is the Stanford B Dissection?
How is it treated?
A
- Descending thoracic Aorta
- Pts with an acute, but uncomplicated type B aortic dissection who have normal hemodynamics, no periaortic hematoma, and no branch vessel involvement can be treated with medical therapy
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18
Q
For Stanford B Dissection, what does medical therapy consist of?
In-hospital mortality rate?
Long-term survival rate with medical therap
A
- intraarterial monitoring of SBP and UOP
- drugs to control BP and the force of LV contraction (BBs, Cardene, SNP)
- in-hospital mortality rate: 10%
- long-term survival rate with medical therapy: 60-80% at 5 years and 40-50% at 10 years
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19
Q
When is surgery indicated for stanford B dissection?
A
- Have signs of impending rupture: persistent pain, hypotension, left-sided hemothorax; ischemia of the legs, abdominal viscera, spinal cord, and/or renal failure
- Surgical treatment of distal aortic dissection: 29% in-hospital mortality rate
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20
Q
Risk factors for aortic dissection:
A
- HTN
- atherosclerosis
- aneurysms
- fam hx
- cocaine use
- inflammatory diseases
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21
Q
Inherited disordes that can cause aortic dissection:
A
- Marfans
- Ehlers Danlos
- Bicuspid Aortic Valve
- non-syndrome familial hx
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22
Q
What can cause an aortic dissection?
Who is a dissection more common in?
A
- Causes of dissection: blunt trauma, cocaine, iatrogenic (c/b medical treatment)
- Dissection more common in men and pregnant women in 3rd trimester
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Iatrogenic causes related to: cardiac catheterization, aortic manipulation, cross-clamping & arterial incision
23
Q
Compare aortic aneuyrysm to dissections
A
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24
Q
In Aortic Aneurysm Rupture, what is the triad of sx experienced in about ½ of cases?
A
- Hypotension
- Back pain
- A pulsatile abdominal mass
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25
Most abdominal aortic aneurysms rupture into the _____ ________.
left retroperitoneum
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Why is Euvolemic resuscitation deferred in Aortic Aneurysm Rupture
* Deferred until the rupture is surgically controlled
* Results in an increase in blood pressure without control of bleeding may lead to loss of retroperitoneal tamponade, further bleeding, hypotension, and death
| Slide 14
## Footnote
suspected ruptured abdominal aortic aneurysm require immediate operation without preoperative testing or volume resuscitation
27
What are the 4 Primary causes of mortality r/t surgeries of thoracic aorta
* MI
* Respiratory failure
* Renal failure
* Stroke
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Preoperative evaluation for aortic dissections include
* Assess for presence of CAD, valve dysfunction, heart failure
* Assess for renal dysfunction
* H/o stroke or TIA
* Assess for carotid stenosis
* Ischemic heart dz may require intervention prior to surgery
* Cardiac evaluation tests: stress test, echo, radionuclide imaging
* Severe reduction in FEV1 or renal failure may preclude a pt from AAA resection
* Smoking/COPD = predictors of post aortic surgery respiratory failure
* PFTs & ABGs help define risk
* Consider bronchodilators, abx, chest physiotherapy
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_____ = predictors of post aortic surgery respiratory failure
Smoking/COPD
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30
What interventions can help prevent pos-aortic surgery renal failure?
* Preop hydration
* Avoid hypovolemia, HoTN & low cardiac output
* Avoid nephrotoxic drugs
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31
For patients with h/o the following, what work up needs to be done prior to elective surgery?
* strokes/TI
* Severe carotid stenosis
**h/o stroke or TIA**:
* Carotids ultrasound
* Angiogram of brachiocephalic & intracranial arteries
**Severe carotid stenosis**
* CEA
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32
________ is caused by lack of blood flow to the anterior spinal artery. It is responsible to perfusing the _______.
* Anterior spinal artery syndrome
* anterior 2/3 of the spinal cord
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33
Ischemia of the anterior spinal artery leads to?
* loss motor function below the infarct
* diminished pain and temperature sensation below the infarct
* antonomic dysfunction leading to hypotension and loss of bowel & bladder function
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34
Why is the anterior spinal artery syndrome is the most common form of spinal cord ischemia?
* the anterior spinal artery has minimal collateral perfusion, making it particularly vulnerable
* posterior spinal cord is perfused by two posterior spinal arteries, allowing for better collateral circulation
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35
What are the common causes of ASA syndrome
* Aortic aneurysms
* aortic dissection
* atherosclerosis
* trauma
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36
What are the 2 subtypes of Cerebral Vascular Accidents?
What dx is the prominent predictor of CVA
* ischemic (87%) or hemorrhagic (13%)
* Carotid dz
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## Footnote
CVA=1st leading cause of disability in the US and
3rd leading cause of death in US
37
What are TIA?
* subset of self-limited ischemic strokes
* sx resolve within 24h
* TIA’s have 10x greater rx of subsequent stroke
| Slide 18
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What are the inheritide and modifiable risk factors for cerebral vascular accident?
39
What are the diagnostic testings for carotid disease?
* Angiography- can dx vascular occlusion
* CT & MRI- less invasive, may also identify aneurysms & AVMs
* Transcranial doppler US- may give indirect evidence of vascular occlusions with real-time bedside monitoring
* Carotid auscultation- can identify bruits
* Carotid US- can quantify degree of carotid stenosis
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40
Where does carotid stenosis occur commonly?
Workup includes?
* Internal/external carotid bifurcation due to turbulent blood flow at the branch-point
* evaluation for sources of emboli s/a A-fib, heart failure, valvular vegetation, or paradoxical emboli in the setting of PFO
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41
Treatment of CVA inclues:
1. TPA within ____
2. Interventional radiology:
3. Surgical treatment:
4. Ongoing medical therapy:
1. 4.5h
2. intra-arterial thrombolysis or
Intravascular thrombectomy
1. Carotid Endarterectomy (CEA) or Carotid stenting
2. Antiplatelet tx, Smoking cessation, BP control , Cholesterol control, Diet & Physical activity
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## Footnote
Carotid stenting is an alternative to CEA with major risk of microembolization→CVA
42
Preoperative evaluation for CEA:
1. Neurologic evaluation: Establish preop deficits
2. Cardiovascular dz
3. HTN
4. Maintain collateral blood flow through stenotic vessels
5. Extreme head rotation/flexion/extension may compress contralateral artery flow
6. Cerebral Oximetry devices
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## Footnote
Most compromised area should take priority if pt has both severe carotid and CAD dx.
43
CPP
MAP - ICP
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44
____ is prevalent in carotid dz.
IIII is a major cause of perioperative M & M in CEA
* CAD
* MI
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45
Cerebral Oxygenation effected by
* MAP
* COP
* Sa02
* HGB
* PaC02
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46
Cerebral 02 consumption effected by:
* Temperature
* Anesthesia
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# Peripheral Artery Disease
1. What is Peripheral Artery Disease?
2. How is it defined?
3. Chronic hypo-perfusion is typically due to ______
4. Acute occlusions are typically due to ______
5. Pt w/PAD have 3-5x increased risk of ___ & ____.
6. Incidence increases ____
1. Results in compromised blood flow to the extremities
2. Defined by an ankle-brachial index (ABI) <0.9
3. atherosclerosis or vasculitis
4. embolism
5. MI & CVA
6. w/age, exceeding 70% by age 75
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## Footnote
ABI= ratio of SBP @ ankle : SBP @ brachial artery
48
Risk factors for Peripheral Artery Disease
* Advanced age
* Family hx
* Smoking
* DM
* HTN
* Obesity
* ↑Cholesterol
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49
Signs & Symptoms for Peripheral Artery Disease
How is relief achieved?
* Intermittent claudication
* Resting extremity pain
* Decreased pulses
* Subcutaneous atrophy
* Hair loss
* Coolness
* Cyanosis
* Relief w/hanging LE over side of bed (↑hydrostatic pressure)
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50
Peripheral Artery Disease Diagonistic tools
1. **Doppler U/S:** provides a pulse volume waveform identifies arterial stenosis
1. **Duplex U/S**: can identify areas of plaque formation & calcification
1. **Transcutaneous oximetry**: can assess the severity of tissue ischemia
1. **MRI w/contrast angiography**: used to guide endovascular intervention or surgical bypass
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51
Medical tx and medical interventions for Peripheral Artery Disease
2 type of repairs?
* Medical Tx: exercise, BP control, cholesterol control, and glucose control
* Medical Intervention: revascularization indicated w/disabling claudication or ischemia
**Repairs**
* Surgical reconstruction- arterial bypass procedure
* Endovascular repair-transluminal angioplasty or stent placement
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52
Common causes of Acute Artery Occlusion
Common causes:
* Left atrial thrombus arising from Afib
* Left ventricular thrombus arising from dilated cardiomyopathy after MI
Less common causes:
* Valvular heart dz, endocarditis, PFO
* Noncardiac causes: atheroemboli, plaque rupture, hypercoagulability, trauma
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53
Diagnosis and tx for Acute Artery Occlusion
* Dx: Arteriography
* Tx: Surgical embolectomy, anticoagulation, amputation (last resort)
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54
What is Subclavian Steal Syndrome
Occluded Subclavian artry [SCA], proximal to vertebral artery causing vertebral artery blood flow to be diverted away from brainstem
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55
Sx, risk factors, and tx for Subclavian Steal Syndrome
**Sx**
* Syncope, vertigo, ataxia, hemiplegia, ipsilateral arm ischemia
* Effected arm SBP may be ̴20mmhg lower
* Bruit over SCA
**Risk Factors**
* Atherosclerosis, Takayasu Arteritis, aortic surgery
**Tx**:
* SC endarterectomy is curative
| Slide 27
56
# Raynaud's Phenomenon
1. What is it?
2. Who does it effect
3. Sx?
4. Dx?
5. Tx?
1. Episodic vasospastic ischemia of the digits
2. women > men
3. Sx: digital blanching or cyanosis w/cold exposure or SNS activation
4. Dx: based on history & physical
5. Tx: protection from cold, CCBs, alpha-blockers. Surgical sympathectomy for severe ischemia
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57
Causes of Raynaud's Phenomenon
58
What are the common Peripheral Venous Disease [PVD] processes that occur during surgery:
* Superficial thrombophlebitis
* Deep vein thrombosis
* Chronic venous insufficiency
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59
3 major factors that predispose to venous thrombosis is called? what are the factors?
Virchows Triad
* Venous stasis
* Hypercoagulability
* Disrupted vascular endothelium
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60
What is a major concern for Peripheral Venous Disease and why?
* DVT- bc it can lead to PE, a leading cause of perioperative M & M
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61
Risk factors for thromboemolism
62
# Superficial Thrombophlebitis & DVT
1. Common during?
2. Occur in appoximately
1. Surgery
2. 50% total hip replacements
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63
# DVT
1. s/sx
1. risk factors
1. diagnositic
1. interventions
2. ____ can greatly ↓risk d/t earlier postop ambulation
1. extremity pain and swelling
2. >age 40, surgery >1h, cancer, ortho surgeries on pelvis & LEs, abdominal surgery
3. Doppler U/S sensitive for detecting proximal thrombosis > distal thrombosis. Venography and impedance plethysmography
4. SCD’s, SQ heparin 2-3x/day
5. Regional anesthesia
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64
Low, moderate, and high risk for DVT after surgery or trauma
65
What is the algorhythm if DVT is suspected?
Contrast Venography
* Normal: DVT ruled out
* Abnormal: intraluminal filling defect in > 2 views = DVT diagnosed
Compression Ultrasonography
* Normal ➡ repeat on day 2 and day 7 ➡ Normal = DVT ruled out
* Abnormal = DVT diagnosed
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66
DVT medicaiton treatment includes?
Warfarin + Heparin or LMWH
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67
What are the LMWH advantages over unfractionated heparin? Disadvantages?
**Advantages**
* longer HL & more predictable dose response
* doesn’t require serial assessment of activated partial thromboplastin time
* Less risk of bleeding
**Disadvantages**
* Higher cost
* Lack of reversal agent
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68
# DVT Tx
_____ is initiated during heparin treatment and adjusted to achieve INR btw ___.
* Warfarin (vit K antagonist)
* 2-3
* Heparin discontinued when Warfarin achieves therapeutic effect
| slide 34
## Footnote
PO anticoagulants continued 6 months or longer. An IVC filter may be placed in pts w/ recurrent PE, or have contraindication to anticoagulants
69
What is Systemic Vasculitis
* Diverse group of vascular inflammatory diseases with characteristics that are often grouped by the size of the vessels at the primary site of the abnormality
* vasculitis can be a feature of connective tissue diseases such as systemic lupus erythematosus and rheumatoid arthritis
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# Systemic Vasculitis
Large-artery vasculitis includes:
* Takayasu arteritis
* Temporal (or giant cell) arteritis
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# Systemic Vasculitis
Medium-artery vasculitis includes:
Kawasaki disease, which is most prominently the coronary arteries
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72
# Systemic Vasculitis
Medium to small-artery vasculitis includes:
* thromboangiitis obliterans
* Wegener granulomatosis
* polyarteritis nodosa
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1. What is Temporal (Giant Cell) Arteritis
2. Sx?
3. seen in what age?
3. Tx?
4. Dx?
5. closely linked with?
1. Inflammation of arteries of the head and neck
2. Sx: unilateral; headache, scalp tenderness, jaw claudication. Opthalmic Arterial branches may lead to ischemic optic neuritis and unilateral blindness
3. People > 50 yo
3. Tx: Corticosteroids indicated for visual symptoms, to prevent blindness
4. Dx: Biopsy of temporal artery shows arteritis in 90% of pts
5. Polymyalgia rheymatica
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# Thromboangiitis Obliterans “Buerger Disease”
1. What is it?
2. Triggered by?
3. Disposing factor?
4. Prevelence in?
5. Diagnosis?
1. Inflammatory vasculitis leading to small & medium vessel occlusions in the extremities
2. Autoimmune response triggered by nicotine
3. Tobacco use is most predisposing factor
4. Most prevalent in men <45
5. biopsy of vascular lesions
| slide 37
75
# Thromboangiitis Obliterans “Buerger Disease”
5 diagnostic criteria for Thromboangiitis Obliterans “Buerger Disease”
1. h/o smoking
1. onset before 50
1. infrapopliteal arterial occlusive dz
1. upper limb involvement
1. Absence of risks factors for atherosclerosis (outside of tobacco)
| slide 37
76
# Thromboangiitis Obliterans “Buerger Disease”
1. Sx?
2. Tx?
3. Anesthesia implications?
Symptoms:
* forearm, calf, foot claudication
* Ischemia of hands & feet
* Ulceration and skin necrosis
* Raynaud's is commonly seen
Treatment
* Smoking cessation-most effective tx
* Surgical revascularization
* No effective pharmacological tx
| Slide 38
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# Thromboangiitis Obliterans "Buerger Disease”
Anesthesia Implications for Thromboangiitis Obliterans “Buerger Disease”
Anesthesia implications
* Meticulous positioning/padding
* Avoid cold; Warm the room and use warming devices
* Prefer non-invasive BP and conservative line placement
| slide 38
78
# Polyarteritis Nodosa
1. What is it?
2. Associated with?
3. Arteries involved
3. Results in?
4. Cause of death?
1. Antineutrophyl cytoplasmic antibody (ANCA) negative vasculitis
2. May be assoc w/ Hep B, Hep C, or Hairy Cell Leukemia
3. Small & medium arteries involved
4. Glomerulonephritis, myocardial ischemia, peripheral neuropathy and seizures. HTN generally caused by renal dz
5. Renal failure is primary cause of death
| slide 39
79
# Polyarteritis Nodosa
Polyarteritis Nodosa tx and anesthesia implications
* Tx: steroids, cyclophosphamide, treating underlying cause (s/a cancer)
* Anesthesia Implications: consider coexisting renal dz, cardiac dz, and HTN
* Steroids likely beneficial
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80
# Lower Extremity Chronic Venous Disease
1. Cause?
2. Prevelence?
3. Mild sx?
4. Severe sx?
1. Long standing venous reflux & dilation
1. Effects 50% of the population
1. Ranges mild-severe
1. Mild sx: telangiectasias, varicose veins
1. Severe sx: edema, skin changes, ulceration
| slide 40
81
Risk factors for Lower Extremity Chronic Venous Disease
* advanced age
* family hx
* pregnancy
* ligamentous laicity
* previous venous thrombosis
* LE injuries
* prolonged standing
* obesity
* smoking
* sedentary lifestyle
* high estrogen levels
| Slide 40
82
# Lower Extremity Chronic Venous Disease
Diagnostic criteria?
Tx?
**Diagnostic criteria**
* Sx of leg pain, heaviness, fatigue
* Confirmed by ultrasound showing venous reflux
* Retrograde blood flow > 0.5 seconds
**Treatment**: initially conservative
* Leg elevation
* Exercise
* Weight loss
* Compression therapy
* Skin barriers/emollients
* Steroids
* Wound management
| SLIDE 41
83
# Lower Extremity Chronic Venous Disease
Conservative medical management
* Diuretics
* Aspirin
* Antibiotics
* Prostacyclin analogues
* Zinc sulphate
*If management fails, ablation may be performed
| slide 42
84
What are the different methods for ablation for Chronic Venous Dz
* Thermal ablation w/laser
* Radiofrequency ablation
* Endovenous laser ablation
* Sclerotherapy
| slide 43
85
For chronic venous sx, what are the indications for ablations?
* Venous hemorrhage
* Thrombophlebitis
* Symptomatic venous reflux
| slide 43
86
Ablation for Chronic Venous Dz is CI in?
* Pregnancy
* Thrombosis
* PAD
* Limited mobility
* Congenital venous abnormalities
| slide 43
87
What are some lower Extremity Chronic Venous Dz surgical interventions?
* Saphenous vein inversion
* High saphenous ligation
* Ambulatory Phlebectomy
* Transilluminated-powered phlebectomy
* Venous ligation
* Perforator ligation
| Surgical intervention-usually last resort
## Footnote
slide 44
88
______ are the leading cause of perioperative morbidity and mortality in patients undergoing noncardiac surgery
Cardiac complications
| slide 45
89
Atherosclerosis is a ____ disease. Pts with peripheral arterial dz have a ____ times greater risk of _______ events
* systemic
* 3-5
* cardiovascular ischemic
| slide 45
90
Carotid artery stenosis with a residual luminal diameter of _____ (____% stenosis) represents significant stenosis. If collateral cerebral blood flow is not adequate, _____ & _____can occur
* 1.5 mm
* 70–75%
* TIAs and ischemic infarction
| slide 45
91
____ & ______ may be observed frequently during and after carotid endarterectomy
Hypertension and hypotension
| slide 46
92
Acute arterial occlusion is typically caused by _______. Emboli may arise from a thrombus in the _____ that develops because of ____.
* cardiogenic embolism
* left ventricle
* MI or dilated cardiomyopathy
| slide 46
93
Other cardiac causes of systemic emboli are
* valvular heart disease
* prosthetic heart valves
* infective endocarditis
* left atrial myxoma
* Afib
* atheroemboli
| slide 46
94
________ is an inflammatory vasculitis leading to occlusion of small and medium-sized arteries and veins in the extremities
Thromboangiitis obliterans
| slide 46
95
Pts at low risk for DVT require
* minimal prophylactic measures such as early postop ambulation and compression stockings
| slide 47
96
The risk of DVT may be much higher in these patients
* >40 y/o
* surgery >1 hour
* LE orthopedic, pelvic or abdominal surgery
* Surgeries that require a prolonged bed rest or limited mobility
| slide 47
97
_____ repair of aortic lesions is a relatively new technique with significant improvements in perioperative mortality
Endovascular
| slide 47
