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Major Vascular II Flashcards

1
Q

What is an aneurysm?

A

A localized enlargement of an artery caused by a weakening of the arterial wall

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2
Q

Multifactorial causes of an aneurysm.

A
  • Adventitial elastin degradation
  • Chronic inflammation
  • Concomitant aortoiliac occlusive disease (20-25%)
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3
Q

An aortic dissection is a rupture of which layer?

A

Intimal layer

This will create a false lumen and pooling of blood in the aneursym, tempoary tamponade.

Eventual expansion and rupture.

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4
Q

Risk factors for Abdominal Aortic Aneurysm

A
  • Frequent in elderly men (8%)
  • Smoking
  • Family history of AAA
  • Atherosclerotic disease
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5
Q

Risk factors for Thoracic Aortic Aneurysm

A
  • Congenital syndromes
  • Trauma
  • Aortic cannulation
  • Bicuspid aortic valve
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6
Q

Risk of rupture R/T luminal diameter of aneurysm: 5.0 to 5.9 cm

A

3-15%

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7
Q

Risk of rupture R/T luminal diameter of aneurysm: 6.0 to 6.9 cm

A

10-20%

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8
Q

Risk of rupture R/T luminal diameter of aneurysm: 7.0 to 7.9 cm

A

20-40%

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9
Q

Risk of rupture R/T luminal diameter of aneurysm: > 8.0 cm

A

30-50%

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10
Q

The surgical mortality rate for abdominal aortic aneurysm

A

2-4%

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11
Q

The surgical mortality rate for thoracic aortic aneurysm

A

20%

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12
Q

The mortality rate of abdominal aortic aneurysm if ruptured prior to hospital admission

A

90%

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13
Q

Risk of paraplegia with thoracic aortic aneurysm

A

4-40%

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14
Q

Risk of renal failure with thoracic aortic aneurysm

A

3-30%

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15
Q

Risk of respiratory failure with thoracic aortic aneurysm

A

8-14%

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16
Q

Classify the aneurysm aneurysm.
Characteristics.

A
  • Saccular Aneurysm
  • Eccentric dilation
  • Variably sized neck
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17
Q

Classify the aneurysm aneurysm.
Characteristics.

A
  • Fusiform Aneurysm
  • Uniform dilation of the entire circumference
  • More common than saccular aneurysm
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18
Q

How are thoracic aortic aneurysms typically discovered?

A

Typically found on imaging and routine exams

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19
Q

What are the symptoms of thoracic aortic aneurysm?

A
  • Non-specific symptoms
  • Hoarseness
  • Stridor
  • Dysphagia
  • Upper body edema
  • Acute, sharp pain
  • BP pressure changes
  • Absence of peripheral pulses
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20
Q

What methods are used to diagnose thoracic aortic aneurysm?

A
  • CXR: widened mediastinum
  • CT/MRI
  • TEE (easy and safe in acute dissection)
  • Angiography
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21
Q

What are the three aortic branches?

A
  • Brachiocephalic trunk (Innominate Artery)
  • Left common carotid artery
  • Left subclavian artery
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22
Q

What do the yellow arrows indicate?

A
  • Widened mediastinum
  • Thoracic aortic aneurysm
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23
Q

Describe the type of aortic dissection and the percentage of occurrence.

A
  • DeBakey I
  • Stanford A
  • Proximal
  • 60%
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24
Q

Describe the type of aortic dissection and the percentage of occurrence.

A
  • DeBakey II
  • Stanford A
  • Proximal
  • 10-15%
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25
Q

Describe the type of aortic dissection and the percentage of occurrence.

A
  • DeBakey III
  • Stanford B
  • Distal (no involvement w/ ascending aorta arch)
  • 25-30%
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26
Q

Classic abdominal aortic aneurysm triad.

A
  • Hypotension
  • Back pain
  • Pulsatile mass
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27
Q

Most AAA will rupture into what space?

A

Left retroperitoneum

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28
Q

Why delay euvolemic resuscitation in AAA?

A
  • Keep hypotensive to limit pressure into the false lumen
  • Rupture can create a temporary retroperitoneal tamponade, slowing down the bleeding briefly.
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29
Q

The gold standard for diagnosing an AAA?

A

Angiography

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30
Q

Preop Anesthetic Management for Aneurysm Repair

A
  • Assessment of Organ System (Previous MI, Cardiac, CABG/CEA, CHF, etc)
  • Hx of COPD/Smoking (PFT/ABGs)
  • Renal Protection (preop hydration, avoid low CO)
  • Avoid nephrotoxic drugs (dye)
31
Q

Anesthesia Induction Considerations for Aneurysm Repair

A
  • Minimize hypertension/ rupture
  • Consider DLT for exposure for TAA
  • CVP/PAP/Flo-Trac
  • A-line
  • Hotline
  • Warmer (underbody)
  • Heparin/ACT/Reversal
32
Q

The most common approach used in aneurysm repair

A
  • Trans-peritoneal
  • Aorta can be accessed through peritoneum
33
Q

Complications with a trans-peritoneal approach for aneurysm repair

A
  • More fluid shifts
  • Ileus
  • Pulmonary complications
  • Longer ICU stay
34
Q

When would a retroperitoneal approach (later border of left rectus muscle) be used in an aneurysm repair?

A
  • Obesity
  • COPD
  • Previous abdominal surgeries
35
Q

Complications with a retroperitoneal approach for aneurysm repair

A
  • More hernias
  • Chronic wound pain
  • Poorer visualization
36
Q

The benefits of using the retroperitoneal approach for aneurysm repair.

A
  • Less fluid shifts
  • Less pulm/abd issues
37
Q

What will happen to SVR during intraoperative aortic clamping?

A

Increase SVR

38
Q

What will initially happen to CO during intraoperative aortic clamping?

A

Decrease CO (no HR change)

39
Q

Impedance to aortic flow will release ____________

A

Catecholamines

40
Q

What is the change in renal vascular resistance from aortic clamping?

A

Resistance increases by 70%

41
Q

Aortic clamping will activate vasoconstriction, which will have what effect on preload?

A

Increase preload

42
Q

Interventions to mitigate the effects of aortic clamping.

A
  • Small boluses of vasodilators prior to clamp (Nitroglycerine/Cardene)
  • Preload alteration
  • Normalize/ replace blood loss with PRBC as Hct drops
  • Use of epidural catheter (vasodilation)

You are trying to get blood to leave the central circulation and go to the periphery to increase preload

43
Q

What will happen to SVR during intraoperative aortic unclamping?

A

Substantial drop in SVR

44
Q

What are the causes of hypotension from aortic unclamping?

A
  • Blood pooling
  • Hypoxia-mediated vasodilation
  • Accumulation of metabolites
45
Q

Interventions to mitigate the effects of aortic unclamping.

A
  • Prepare for sudden hemodynamic collapse
  • Fluids to CVP goal (fill up the tank)
  • Decrease VA
  • Small does of vasoconstrictor (neo pushes)
  • Labs (ABG/Hct/K+)
  • Ask the surgeon to unclamp judiciously
  • Consider: Calcium, bicarb, low dose pressors)
46
Q

Which arm will be used to measure NIBP during aortic clamping?

47
Q

Desired MAP above and below the aneurysm

A
  • 100 mmHg above
  • 50 mmHg below
48
Q

What does a TEG measure?

A
  • Viscoelastic properties of a clot
  • Clot Strength
  • Clot Formation efficiency
  • Clot Fibrinolysis
49
Q

What does the R-time of a TEG indicate?

A

Reaction time to clot formation

50
Q

What does the K-time of a TEG indicate?

A

Time for the clot to achieve a certain clot firmness

51
Q

What does the α-Angle of a TEG indicate?

A

Rate at which clot develops

52
Q

What does the MA of TEG indicate?

A

Maximum strength of the clot/ platelet number

53
Q

What does the LY30 indicate on a TEG?

A

Percent of clot lysis after 30 minutes

54
Q

Which part of the spinal column reflects the sensory tracts?

A

Dorsal spinal column

55
Q

Which part of the spinal column reflects the motor tracts?

A

Anterior spinal column

56
Q

When can local anesthetics be added to an epidural during an aneurysm repair?

A

After aortic unclamping and stabilization

57
Q

Damage to the posterior spinal arteries will affect which tract?

A

Sensory Tract (Paresis)

58
Q

Damage to the anterior spinal artery will affect which tracts?

A

Motor Tract (Paraplegia)

59
Q

The artery of Adamkiewicz most commonly arises at the level of _________ (range)

60
Q

The anterior radicular artery is usually between these levels.

61
Q

What causes GI and renal ischemia during aneurysm repair?

A

↑ SVR and ↓ CO when aortic clamps are on

62
Q

Clamp distal to left subclavian artery will have what percent decrease in renal flow?

What about clamps applied below the kidneys (infrarenal)?

A
  • 90% decrease in flow (distal to left subclavian)
  • 30% decrease (infrarenal)
63
Q

The benefits of using a left heart bypass to maintain lower body perfusion during aneurysm repair.

A
  • Allows adjustment of flow
  • Oxygenator unnecessary
  • Relieves ↑ afterload
  • Full bypass dose of heparin not required
64
Q

Why would deep hypothermic circulatory arrest (DHCA) be used in aortic aneurysm repair?

A
  • Brain protection
  • Improved Visualization
  • Blood control
65
Q

Body temp for DHCA?

66
Q

Blood flow for DHCA?

A

400-500 cc/min

67
Q

How long can a body be in DHCA before a significant increase in brain injury?

A
  • 30 mins
  • Anything over 40 mins can hurt the brain
68
Q

What area does an endovascular aneurysm repair focus on?

A

Descending thoracic aorta and abdominal aorta

69
Q

Complications that may arise if a stent is placed in areas where the aneurysm has a high-pressure aortic flow?

A
  • Kinking
  • Structural Failure
  • Device Migration
70
Q

Anesthesia Management of Endovascular Aneurysm Repair

A
  • General/regional/sedation
  • Arterial line
  • Large bore IV access
  • Blood availability
  • Heparin/ACT/Protamine like any vascular procedure
71
Q

Complications of Endovascular Aneurysm Repair

A
  • Endoleaks
  • Vascular injury during deployment
  • Inadequate sealing
  • Migration
  • Frame fracture
  • Thrombosis of stent
72
Q

What does ALARA stand for in radiation safety?

A

As Low As Reasonably Achievable

73
Q

Contrast dye can increase creatine by how much?

A

25% increase in Cr usually 2-3 days post-op

Limit contrast amount
Provide adequete hydration

74
Q

Risk factors for contrast-induced nephropathy

A
  • Contrast load
  • Pre-existing disease

Advanced Principles C (11 decks)

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