Grayson's Deck: Vascular Disease Flashcards
What are some coexisting diseases that are commonly seen in vascular surgery patients? Which 3 are the MOST common?
- CAD - 40-80% of vasc patient have this;
- HTN- (most common);*
- Diabetes- (most common);
- Smokers- (most common);
- CNS; carotid disease stroke;
- Renal
What percentage of vascular surg patients will have an MI postop that results in death?
- 50% (not in the acute phase though)
If the surgical site has sclerosis what should we assume?
- that other areas are sclerotic as well
What are the risk factors for vascular disease?
- Diabetes mellitus;
- Dyslipidemia;
- Family history;
- Hypertension;
- Obesity;
- Older age: 75 y/o and up;
- Smoking (2x)
What is the most common occlusive disease in the lower extremity arteries?
- Atherosclerosis
What are three pathophysiologic processes that affect arteries?
- Plaque formation;
- Thrombosis;
- Aneurysm formation
What are 4 S/Sx associated with peripheral occlusive disease?
- Claudication;
- skin ulcerations;
- gangrene;
- impotence
What are two common causes of vascular aneurism?
- HTN;
- Vascular damage
If a patient is on ED drugs what should we assume?
- That vascular disease is everywhere in the body → thats why they have impotence
What is the treatment for
peripheral occlusive disease?
- Pharmacologic therapy OR;
- Transluminal angioplasty;
- Endarterectomy;
- Thrombectomies;
- Multiple bypass procedures
In a patient with vascular disease what other issues should we be sure to evaluate in preop? Why does it matter?
- CAD;
- pulm dysfunction;
- renal dysfunction;
- neuro dysfunction;
- endocrine dysfunction;
- Matters d/t disease process not being limited to arterial beds in periphery → its everywhere
What is the primary goal for invasive monitoring of a vascular surg patient?
- detection of cardiac ischemia → a-line may be important for these patients
What monitoring should we consider for a vascular surg patient?
- Depending on patient:;
- a-line PA cath and TEE are all warranted for assessing CV function
How should we approach anesthetic selection for a vascular disease patient?
- Depends on surg type but consider:;
- LA and IV concious sedation;
- Regional anesthesia;
- General anesthesia
Why are spinals and epidurals controversial for peripheral vascular surgery?
- patient is being anticoagulated
What are two important issues after peripheral vascular surgery?
- Pain management;
- Monitoring
When doing bypass grafting on upper/lower extremities for occlusive disease or aneurysms what are some viable anesthesia options?
- General;
- Regional
What can cause intermittent claudication?
- When demand exceeds supply
- Demand ischemia
What is “Rest Pain”?
- Rest pain is a constant burning pain from wounds that won’t heal.;
- Associated with peripheral vascular disease
What can improve “Rest Pain”?
- ↑ hydrostatic pressure → albumin can help with this
What are some Dx of PVD?
- ↓ or absent pulses;
- Bruits in abdomen pelvis inguinal area (remember clots often happen at bifurcations)
- Intermittent Claudication
- Rest Pain
- Use ultrasound to assess vascular flow
If a patient presents with hair loss on their lower extremities what should you think of?
- Peripheral vascular disease causes subq atrophy and hair loss
What are the three classifications of the Ankle-brachial index?
- If ABI is:;
- < 0.9 claudication;
- < 0.4 rest pain;
- < 0.25 impending gangrene
What is the ankle-brachial index (ABI)? How do we calculate it?
- the ratio of the BP at ankle to BP in upper arm;
- Ankle SBP / Arm SBP
If the BP in the leg is lower than BP in the arm what does that tell us?
- ↓ leg BP indicates blocked arteries d/t PAD
What are some treatment options for PVD?
- Exercise;
- Stop smoking;
- Treat HTN CAD DM;
- β-antagonists MAYBE → If someone has demand ischemia Beta blockers can reduce peripheral perfusion;
- ↓ lipids;
- Revascularization vs amputation
When might revascularization for PVD be considered?
- Disabling claudication;
- Ischemic rest pain;
- Impending limb loss
What are the main components of the revascularization procedure?
- Angioplasty;
- May stent may not;
- Iliac and femoral/popliteal arteries common
What are some anesthesia concerns with revascularization cases?
- patients prob too sick to do surgical CAD → need pharmacological stress test;
- if pt on β blockers, please continue them.
- Vessels often harvested from other areas of body so regional might be tricky;
- Patient will be anticoagulated → more bleeding
What is the 3rd leading cause of death in the U.S.?
- Stroke
What two types of stroke are there and which is the most common?
- Hemorrhagic and Ischemic;
- Ischemic is more predominant
What is the difference between a TIA and a Stroke?
- TIA always caused by temporary ischemia never bleeding. Stroke can be bleeding or ischemia
What does a TIA suggest?
- impending stroke
How strong is the correlation between TIA and impending stroke?
- 10x more likely than age/sex matched
What are risk factors for stroke?
- Age;
- Atrial fibrillation;
- Black race;
- History/family history;
- HTN/smoking/diabetes;
- Hypercholesterolemia;
- Male;
- Obesity;
- Sickle cell disease
In the brain which vessel is the most common place for a clot to occur?
- Internal carotid
What are some ways we might diagnose carotid artery disease?
- Angiography;
- Carotid bruit;
- Carotid stenosis;
- Sudden neurological deficits
Where does carotid stenosis most often occur?
- Carotid bifurcation → most common place for atherosclerotic plaque buildup
How do we treatment an acute ischemic stroke?
- TPA within 3-5 hrs (NNT=10 →https://www.thennt.com/thennt-explained/);
- Intra-arterial thrombolysis
How can we treat/prevent ischemic strokes in the long term?
- Stop smoking;
- Antiplatelet therapy;
- Correct or ↓ hypoxia hypertension unstable arrhythmias;
- Carotid endarterectomy
Why are cardiac arrythmias common in stroke? What can reduce this risk?
- when the docs start working on the clot pieces break off and travel…;
- Translumenal procedures ↓ this risk
What are some anesthesia concerns for patients receiving intra-arterial thrombolysis?
- Commorbidities → major cause of mortality postop (MI/Stroke biggest mortality);
- Good BP control → want good cerebral autoregulation;
- Consider effects of their head being rotated.
- Consider regional so we can keep them awake to monitor for stroke
What area of the aorta is the most difficult to treat? Which area is easier?
- Ascending more difficult;
- Abdominal less difficult
What are two types of vessel abnormalities we might see on the aorta?
- Aneurysm →Dilation with 50% increase in diameter;
- Dissection →Blood enters media layer from tear in intima
What are two major complications for anesthesia during aorta repair surgery?
- Need to cross-clamp the aorta;
- Potential for large intraoperative blood loss
Related to aortic cross clamping what are some cardiac specific changes that occur?
- Acute ↑↑↑ LV afterload and severe HTN;
- Myocardial ischemia;
- LV failure;
- Aortic valve regurg
Related to aortic cross clamping what are some critical perfusion specific changes that occur?
- Compromises organ perfusion distal to point of occlusion;
- Interrupts BF to spinal cord and kidneys → results in paraplegia and renal failure
What can happen after the aortic clamp is released and why? How do we prevent this?
- Patient might become hypotensive d/t blood loss and not having enough volume to fill system when clamp is released;
- Volume loading can help
What are 5 indications we discussed in class for aortic surgery?
- Aneurysms;
- Aortic dissection;
- Coarctation;
- Occlusive disease;
- Trauma
Related to aortic surgery what are the 4 site specific lesions we need to know?
- Aortic arch;
- Ascending aorta;
- Below the diaphragm;
- Distal to left subclavian artery and above diaphragm
How are aortic dissections classified?
- DeBakey I II III;
- –OR–;
- Stanford A (proximal) or B (Distal)
Describe each of the DeBakey classifications?
- DeBakey I → Dissection in the ascending aorta that extends into the descending aorta;
- DeBakey II → Dissection in the ascending aorta that does notextend into the descending aorta;
- Debakey III → Dissection in the descending aorta distal to left subclavian;
- Debakey IIIA → extension to abdominal aorta;
- Debakey IIIB → doesn’t extend to abdominal aorta
What is an aortic dissection?
- Characterized by a spontaneous tear of the vessel wall intima permitting the passage of blood along false lumen
What is the most common factor contributing to the progression of an aortic dissection? Most serious complication is?
- Common factor = HTN;
- Complication = aneurysm rupture
Stanford classification Type A converts to DeBakey how?
- Stanford Type A = DeBakey I and II
How are dissecting aortic lesions treated?
- Proximal dissections nearly always treated surgically;
- Distal dissections may be managed medically initially;
- Measures to reduce SBP and wall stress are initiated once diagnosis confirmed
Which dissecting aortic lesions have the highest incidence of rupture?
- Proximal lesions (ascending)
What is a “True” aneurysm? What is a “False” aneurysm?
- True → Involves dilation of all 3 layers of the vessel wall;
- False → Caused by disruption of 1 or more layers of the vessel wall
What is the most common location for aortic aneurysms? What is the most common cause?
- abdominal aorta;
- atheroslcerosis or medial cystic necrosis ← he mentions both on slide 36 as being the common cause
What are some important complications of AAA to know?
- Depending on site:;
- aortic regurg;
- tracheal or bronchial compression or deviation;
- hemoptysis;
- superior vena cava syndrome
Which part of the aorta do syphalitic aneurysm generally involve?
- ascending aorta
What is the greatest danger of aortic aneurysm?
- rupture and exsanguination
What is the normal size of the aorta in adults? When would an aortic resection be performed?
- normal = 2-3 cm in width;
- Elective resection done when the aneurysm is > 4 cm
When does a pseudoaneurysm form?
- when the intima and media are ruptured and only the adventitia or blood clotform the out layer of the vessel
Thromboembolic occlusion of the aorta is most commonly due to what?
- atherosclerosis;
- Combo of atheroslerotic plaque and thrombosis
How do we treat thromboembolic occlusion of the aorta?
- Aorto-bifemoral bypass;
- Possible proximal thromboendarterectomy
What are the two types of aortic trauma? What diagnostic shows you that bleeding is occurring?
- Penetrating or non-penetrating injury;
- CXR with wide mediastinum indicates bleeding
Why is it important to do a GOOD preop on vascular surgery patients?
- Patient frequently elderly and lots of concurrent diseases;
- Special attention given to cardiac renal and neuro function;
- Preop renal dysfunction directly r/t postop renal failure
Where is the most common location for a thoracic aneurysm to develop?
- Just above aortic valve distal to left subclavian takeoff → Ligamentum arteriosum
What are risk factors for thoracic aneurysm?
- Age;
- Aortic cannulation;
- Atherosclerosis;
- Blunt trauma;
- Crack cocaine;
- Hypertension;
- Male sex;
- Marfan’s syndrome;
- Smoking
Why is Marfans syndrome prone to causing aneurysms?
- Vasculature can’t keep up with the increased size of patients with the syndrome
What are the two classes of aneurysms?
- Saccular → eccentric dilation;
- Fusiform → entire circumference of aorta
Which class of aneurysm often occurs at the renal arteries?
- Fusiform
What are some S/Sx of a thoracic aneurysm?
- Often asymptomatic and but exam can find:;
- Hoarseness;
- Stridor;
- Dyspnea;
- Dysphagia;
- Dilation of aortic valve annulus
What are some S/Sx of acute aortic dissection?
- Severe sharp tearing pain;
- Hypotension/hypertension;
- Absence of peripheral pulses;
- Paraplegia/paraparesis
How do we diagnose aneurysms/aortic dissections?
- CXR;
- TEE;
- Arteriogram
How are aortic dissections treated?
- Stent;
- Open surgery
What is “anterior spinal artery syndrome”? What are some adverse S/E?
- major complication of cross clamping of thoracic aorta with > 30 min cross clamp times;
- Flaccid paralysis loss of bowel/bladder renal insufficiency;
- Loss of motor function and pinprick sensation but preservation of vibration and proprioception
What famous artery perfuses the anterior spinal artery?
- Artery of Adamkiewicz or the greater radiculmedullary artery
If you notice a patient has a pulsatile abdominal mass on exam what would you suspect?
- Abdominal aneurysm → common in people > 60 y/o
How might we diagnose an abdominal aneurysm?
- Abdominal ultrasound;
- Helical CT - to see if endovascular repair is feasible;
- MRI
What is the treatment regime for abdominal aneurysms?
- <4cm → US q6 mo;
- 4-5cm → elective repair w/low operative risk and good life expectancy.;
- 5-6 cm → need repair (mortality rate 0.9-5%);
- 6-7 cm → threshold for rupture (mortality as high as 75%).
What are the classic S/Sx of an abdominal aneurysm rupture? What percentage of patients do these S/Sx appear?
- Hypotension;
- Back pain;
- Pulsatile mass;
- S/Sx only present in 50% of patients (hemorrhage and tamponade into retroperitoneum also happens)
If we are doing a case where surgery is performed on the ascending aorta which arm are we going to place our art line in? What med will we used to contro BP and why?
- Left radial is used d/t cross clamping of the aorta;
- Will use nitroprusside instead of nicardipine d/t needing fast on/fast off
Surgery on the aortic arch and ascending aorta use what approach?
- Aortic arch → median sternotomy with deep hypothermic circulatory arrest;
- Ascending aortia → cardiopulm bypass
For surgery involving the aortic arch what are import considerations needed to provide the best cerebral protection?
- Know that long rewarming periods contribute to intraoperative blood loss;
- Mannitol;
- Methylprednisolone or dexamethasone;
- Narcotic infusion;
- Phenytoin;
- Systemic and topical hypothermia (15° C)
What is the most common location that the Artery of Adamkiewicz arises?
- T9-T12 (60% of people) → almost always on the left side
Other locations
* T5-T8 (15% of people)
* L1-L2 (25% of people)
How do we calculate spinal cord perfusion pressure?
- Spinal Perf Pressure = MAP - CSF
How might we monitor for paraplegia when doing a case with aortic cross clamping?
- SSEP
What are some protective therapeutic measures we can take before the surgeon cross clamps the aorta?
- Methylprednisolone;
- Mild hypothermia;
- Mannitol (0.5g/kg);
- Renal dose dopamine (1-3 mcg/kg/min);
- Fenoldopam (0.05-0.1 mcg/kg/min);
- Maintain BP;
- Drainage of CSF
What is ↑ renal failure following aortic surgery a result of?
- Emergency procedures;
- Prolonged cross-clamp periods;
- Prolonged hypotension
A PACU patient develops a hematoma after carotid endarterectomy with airway obstruction. What is the best treatment?
Surgical Decompression (the best thing to do overall)
Surgical Cricothyroidotomy (best thing for CRNAs to do)
Which Standard type of Aneurysm does not involve the ascending aorta?
Standford B
Which of the following is a characteristic of Anterior Spinal Artery Syndrome?
A. Paralysis of upper extremities
B. Loss of touch and proprioception
C. Loss of bowels and bladder function
C. Loss of bowels and bladder function
Activation of which reflex may cause bradycardia in carotid surgery?
Baroreceptor
Block out the baroreceptor with Lidocaine.
Which of the following is the most significant factor associated with postoperative renal failure?
A. Pre-operative renal failure
B. Aortic Cross clamp
C. Hypotension
D. Bradycardia
A. Pre-operative renal failure
Which Anesthetic technique is preferred for carotid surgery?
Regional
Which of the following is a risk factor for vascular disease and a complication of its development?
A. DM
B. HTN
C. Renal Failure
D. Smoking 2 PPD
C. Hypertension
Hypertension is the only answer choice that causes vascular disease and also occurs from vascular disease.
The risk of pneumonia is how many times higher in smokers than in non-smokers?
Twice as high in smokers than non-smokers
