Exam 4 - Vascular disease

Question 1

What are the 3 main arterial pathologies?

Answer 1

aneurysms, dissections, and occlusions.

Question 2

What are more likely to be affected by aneurysms and dissections?

Answer 2

Aorta and its branches.

Question 3

What are more likely to be affected by occlusions?

Answer 3

Peripheral arteries.

Question 4

An aortic aneurysm is dilation of all 3 layers of artery, leading to >____% in diamater.

Answer 4

50%

Question 5

Surgery is indicated for an aneurysm thats greater than ___cm in diameter (or ___mm/year), and aneurysms have a ___% mortality rate.

Answer 5

> 5.5cm; 10mm; 75%

Question 6

Medical Tx for aortic aneurysms?

Answer 6

manage BP, cholesterol, stop smoking, avoid strenous exerice/stimulants/stress.

Question 7

an aortic dissection is a tear in the ___ layer of the vessel, causing blood to enter the ____.

Answer 7

Intimal; medial

Question 8

An ascending dissection is ___ and requires __.

Answer 8

catastrophic; emergent surgical intervention.

Question 9

Ascending dissection can be classified as (5 things)

Answer 9

Stanford A/B and Debakey 1, 2, and 3

Stanford A is paired with type 1 and 2, and Stanford B is paired with Type 3.

Question 10

Mortality for an ascending dissection increases ___ per hour and overal mortality is ___.

Answer 10

1-2% per hour; 27-58%

Question 11

Diagnosis for aortic dissection is

Answer 11

CXR, CT, MRI, Angiogram

US if theyre unstable

Doppler echocardiogram is fastest/safest measure

Question 12

2 types of aortic aneurysms are

Answer 12

Saccular (outpouching bulge to one side) and fusiform (uniform)

Question 13

What is a debakey 3/Stanford B?

Answer 13

Tear in the descending aorta

Question 14

What is a Debakey 1/2 or stanford A?

Answer 14

Tear in ascending aorta

Question 15

what type is the most commonly performed aortic procedure?

Answer 15

Stanford A dissection, valve replacement

Question 16

If aortic arch is involved, then ______ is indicated.

Answer 16

surgical resection.

Question 17

Circulatory arrest at a body temp of ____ for ___ minutes can be tolerated by most pateints during procedure.

Answer 17

15-18 degrees; 30-40

Question 18

What is a major complication associated with aortic arch replacement?

Answer 18

Neuro deficit seen in 3-18% of pts

Question 19

Descending thoracic aorta that has normal hemodynamics, no hematoma and no branch vessel involvement can be treated ___

Answer 19

medically.

Question 20

In-hospital mortality rate of descending thoracic aorta is

Answer 20

10%

Question 21

Long term survival rate with medical tx @ 5 and 10 years of descending thoracic aorta is

Answer 21

60-80% @ 5 years and 40-50% @ 10 years

Question 22

When is surgery indicated for stanford b dissection

Answer 22

When signs of impending rupture or compromised perfusion to lower body.

Question 23

Risk factors for aortic dissection

Answer 23

HTN, atherosclerosis, aneurysms, fam hx, cocaine, inflammatory diseases.

Question 24

Inherited disorders of aortic dissection

Answer 24

Marfans, ehlers danlos, bicuspid aortic valve

Question 25

Dissections are more common in

Answer 25

men and 3rd trimester pregnant women

Question 26

Triad of sx seen in 50% of aortic aneurysm ruptures

Answer 26

Hypotension, back pain, pulsatile abdominal mass.

Question 27

Most abdominal aortic aneurysms rupture into

Answer 27

left retroperitoneum

Question 28

If retroperitoneal tamponade occurs, ______ may be delayed until rupture is surgically controlled in order to maintain a lower BP and reduce risk of further bleeding, hypotension, and death.

Answer 28

Volume rescucitation

Question 29

4 primary causes of mortality r/t surgeries of thoracic aorta

Answer 29

MI, Resp failure, renal failure, stroke

Question 30

What may preclude a pt from aortic resection?

Answer 30

Low FEV1 or renal failure

Question 31

What are the predictors of post aortic surgery resp failure?

Answer 31

Smoking/COPD Consider bronchodilators, abx, chest physiotherapy.

Question 32

______ is the most significant indicator of post-aortic surgery renal failure.

Answer 32

Pre-op renal dysfunction **pre-op hydration, avoid hypovolemia/HoTN/low cardiac output/nephrotoxic drugs**

Question 33

If they have hx of stroke or tia, complete this in pre op eval

Answer 33

Carotid ultrasound, angiogram of brachiocephalic/intracranial arteries.

Question 34

Severe carotid stenosis ->

Answer 34

Workup for CEA before elective surgery

Question 35

ASA

Answer 35

Anterior spinal artery syndrome: causes by lack of blood flow to anterior spinal artery (perfuses anterior 2/3rds of spinal cord)

Question 36

Ischemia of the anterior spinal cord causes (3 things)

Answer 36

-Loss of motor function below the infarct -Diminished pain and temp sensation below infarct -hypotension/bowel and bladder dysfunction d/t autonomic dysfunction

Question 37

Whats the most common form of spinal cord ischemia? Why?

Answer 37

ASA d/t minimal collateral perfusion

Question 38

Common causes of ASA syndrome

Answer 38

Aortic aneurysms, aortic dissection, atherosclerosis, trauma

Question 39

CVA's are ___% ischemic and ____% hemorrhagic

Answer 39

87;13

Question 40

Whats the 1st leading cause of disability in the US?

Answer 40

CVA (and 3rd leading cause of death)

Question 41

TIA symptoms resolve within ____hours and have ___ greater risk of a subsequent stroke.

Answer 41

24;10x

Question 42

AHA recommends TPA within ___ hours of onset of CVA

Answer 42

4.5 hours

Question 43

Intravascular thrombectomy has benefits seen up to ___ hours after onset of CVA.

Answer 43

8 hours

Question 44

A carotid endarterectomy (CEA) is a surgical treatment for severe carotid stenosis when the lumen diameter is <___mm or >___% blockage.

Answer 44

1.5mm; 70%

Question 45

What procedure has a major risk of microembolization leading to CVA?

Answer 45

Carotid stenting

Question 46

A major cause of perioperative mortality in CEA is

Answer 46

MI

Question 47

CPP = __ - ___

Answer 47

MAP - ICP

Question 48

Its important to maintain ____ blood flow through stenotic vessels during cross-clamp.

Answer 48

collateral

Question 49

What can compress contralateral artery flow during CEA procedure?

Answer 49

Extreme head rotation/flexion/extension

Question 50

What devices help gauge and trend cerebral perfusion?

Answer 50

Foresight, INVOS

Question 51

Peripheral artery disease is compromised blood flow to extremities and is defined by

Answer 51

ankle-brachial index (ABI) <0.9 Ratio of SBP @ ankle to SBP @ brachial artery ankle/brachial?

Question 52

Chronic hypo-perfusion in PAD is typically due to

Answer 52

atherosclerosis, could also be vasculitis

Question 53

Pt with PAD have ___x increased risk of MI and VA

Answer 53

3-5x

Question 54

Duplex US can identify _____

Answer 54

areas of plaque formation and calcification

Question 55

Doppler US can provide a

Answer 55

pulse volume waveform and identify arterial stenosis

Question 56

Acute peripheral artery occlusion is frequently due to

Answer 56

cardiogenic embolism typically left atrial thrombus d/t AFIB or left ventricular thrombus d/t cardiomyopathy after MI

Question 57

How do you diagnose an acute peripheral artery occlusion?

Answer 57

Arteriogram

Question 58

Subclavian steal syndrome

Answer 58

Occluded SCA, proximal to vertebral artery, vertebral artery flow diverts away from brainstem.

Question 59

The effected arm BP of occluded SCA may have a SBP of ~___mmHg lower and a ___ over the SCA.

Answer 59

20; bruit

Question 60

Treatment for Subclavian steal syndrome?

Answer 60

SC endarterectomy

Question 61

Raynauds effects women more or less than men?

Answer 61

more

Question 62

Tx for raynauds

Answer 62

protection from cold, CCB, alpha-blockers *Surgical sympathectomy for severe ischemia*

Question 63

Chart for raynauds (just look at it)

Answer 63

Question 64

Common PVD processes that occur during surgery

Answer 64

superficial thrombophlebitis, DVT, chronic venous insufficiency.

Question 65

Leading cause of perioperative M&M (what the fuck is that?)

Answer 65

DVT leading to PE

Question 66

Virchow's triad is 3 factors that predispose to venous thrombosis, which include?

Answer 66

venous stasis, disrupted vascular endothelium, hypercoagulability

Question 67

Risk factors for DVT include

Answer 67

age >40, surgery >1h, cancer, ortho surgeries on pelvis and LEs, abdominal surgery. diagnose with US, venography, impedance plethysmography

Question 68

What can greatly reduce risk of DVT periop?

Answer 68

Regional anesthesia d/t earlier postop ambulation.

Question 69

Heres a chart for DVT, just look at it..

Answer 69

Question 70

LMWH disadvantages for DVT treatment

Answer 70

high cost and lack of reversal agent

Question 71

LMWH advantages over unfractionated heparin for DVT

Answer 71

longer HL and more predictable Doesnt require serial assessment of aPTT Less bleeding risk

Question 72

DVT treatment (2 drugs)

Answer 72

warfarin and heparin (or LMWH)

Question 73

Warfarin is is initiated during heparin treatment and adjusted to achieve an INR of

Answer 73

2-3

Question 74

Heparin is d/c'd when warfarin __________

Answer 74

achieves therapeutic effect

Question 75

PO anti-coags are continued for _____ after DVT.

Answer 75

6 months or longer

Question 76

IF you have a recurrent PE with DVT, and/or contraindicated for anticoags, you could get a

Answer 76

IVC filter

Question 77

Systemic vasculitis is a group of vascular inflammatory diseases categorized by ?

Answer 77

The size of the vessels at the primary site of abnormality

Question 78

Large-artery vasculitis includes (2 things)

Answer 78

Takayasu arteritis, temporal (or giant cell) arteritis

Question 79

Medium-artery vasculitis includes

Answer 79

Kawasaki disease which usually only affects the coronary arteries

Question 80

Temporal (Giant cell) Arteritis

Answer 80

Inflammation of arteries of the head and neck causing unilateral headache, scalp tenderness and jaw claudication.

Question 81

How is Temporal arteritis diagnosed and treated?

Answer 81

Biopsy of temporal artery shows arteritis in 90% of patients, treated with corticosteroids if they have visual symptoms to prevent blindness.

Question 82

Temporal Arteritis can lead to what severe complication?

Answer 82

Opthalmic arterial branches may lead to ischemic optic neuritis and unilateral blindness.

Question 83

What is Buerger disease?

Answer 83

Thromboangiitis Obliterans, which is inflammatory vasculitis leading to small and medium vessel occlusions in the extremities.

Question 84

Buerger disease is a ______ response triggered by ____, and most prevalent in men ____ (age).

Answer 84

autoimmune; nicotine; <45

Question 85

5 diagnostic criteria for beurger disease and how is it confirmed if suspected?

Answer 85

smoking, onset before 50, infrapopliteal arterial occlusive disease, upper limb involvement, and absence of risk factor for atherosclerosis outside of tobacco. diagnosis is confirmed with biopsy of vascular lesions.

Question 86

Buerger disease can present like

Answer 86

raynauds

Question 87

Tx of beurger disease

Answer 87

smoking cessation (most effective), surgical revascularization. There is NO effective pharmacological treatment.

Question 88

Anesthesia implications for beurger

Answer 88

meticulous positioning/padding Avoid cold; warm the room and use warming devices Prefer non-invasive BP and conservative line placement.

Question 89

Polyarteritis Nodosa

Answer 89

Vasculitis of small and medium vessels, leading to glomerulonephritis, myocardial ischemia, peripheral neuropathy, and seizures.

Question 90

Polyarteritis may be associated with

Answer 90

Hep B, Hep C, or hairy Cell leukemia

Question 91

What is the primary cause of death in polyarteritis nodosa?

Answer 91

Renal failure

Question 92

Anesthesia implications of polyarteritis nodosa

Answer 92

Consider coexisting renal disease, cardiac disease, and HTN Steroids likely beneficial

Question 93

Lower extremity chronic venous disease effects ___% of the population.

Answer 93

50%

Question 94

Severe sx of LE CVD

Answer 94

edema, skin changes, ulceration

Question 95

Just gonna post the whole damn slide cause there is so much info on LE CVD

Answer 95

Question 96

Diagnostic criteria of LE CVD

Answer 96

leg pain, heaviness, fatigue confirmed by US showing venous reflux and retrograde blood flow >0.5 seconds.

Question 97

Treatment for LE CVD

Answer 97

leg elevation, exercise, lose some damn weight, compression shit, steroids (barry bonds), wound management.

Question 98

Medical management of LE CVD

Answer 98

diuretics, aspirin, abx, prostacyclin analogues, zinc sulphate or ablation if all that shit fails.

Question 99

Last resort for LE CVD is

Answer 99

surgical intervention such as: (i aint remembering this shit) Saphenous vein inversion High saphenous ligation Ambulatory Phlebectomy Transilluminated-powered phlebectomy Venous ligation Perforator ligation