Mod X: ANESTHESIA FOR PERIPHERAL VASCULAR DISEASE Flashcards
ANESTHESIA FOR PERIPHERAL VASCULAR DISEASE
OBJECTIVES
- Discuss the degenerative disease process associated with peripheral vascular disease
- Identify common risks associated with atherosclerosis
- Discuss surgical treatment options for peripheral vascular disease
- Discuss anesthetic management, including benefits of regional anesthesia in this patient population
- Discuss postoperative management of these patients
PERIPHERAL ARTERIAL DISEASE
Incidence:
Common condition
Affecting 10 million Americans
Incidence is rising
Most patients asymptomatic at the begining or they have symptoms other than the classical intermittent claudication, the actual prevalence of the dz is unknown
PERIPHERAL ARTERIAL DISEASE
Most common cause of PAD is:
Atherosclerosis
With the infrarenal and iliac arteries being the most common sites of chronic atherosclerosis (plaque build up), when compared to all other aortic atherosclerotic sites
PERIPHERAL ARTERIAL DISEASE
PVD is strong indicator of generalized arterial disease, including CAD and cerebral vascular disease - why?
Plaque is not usually comfined to the peripheral arterial tree
Patients with CAD and PVD have higher incidence of triple vessel CAD than patients with CAD only
More than 20% of patients with PVD have at least 70% stenosis of carotid arteries
PERIPHERAL ARTERIAL DISEASE
Pts with PVD should have testing prior to any ellective surgery - why?
PVD patients have higher incidence of cardiac M&M following surgery
Peripheral arterial disease = very strong marker of mortality
PERIPHERAL ARTERIAL DISEASE
Non Modifiable risk factors for PAD
Non Modifiable risk factors for PAD
![](https://s3.amazonaws.com/brainscape-prod/system/cm/274/665/910/a_image_thumb.png?1555532667)
PERIPHERAL ARTERIAL DISEASE
Modifiable risk factors for PAD
Modifiable risk factors for PAD
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PERIPHERAL ARTERIAL DISEASE
Graphycal representation of the Natural History of Atherosclerotic Lowe Extremity PAD Syndromes
Graphycal representation of the Natural History of Atherosclerotic Lowe Extremity PAD Syndromes
Note the long history
5 years after diagnosis more pts w/ PVD die from cardiac causes than those who loose limbs
![](https://s3.amazonaws.com/brainscape-prod/system/cm/274/666/183/a_image_thumb.png?1555532853)
PERIPHERAL ARTERIAL DISEASE
5 years after diagnosis more pts w/ PVD die from
A. cardiac causes
B. loss of limbs
A. cardiac causes
B. loss of limbs
ACUTE ARTERIAL OCCLUSION
ACUTE ARTERIAL OCCLUSION is Usually the result of:
an embolus or
a thrombus
![](https://s3.amazonaws.com/brainscape-prod/system/cm/274/666/582/a_image_thumb.png?1555533051)
ACUTE ARTERIAL OCCLUSION
Emboli typically originate from? What are their most common causes?
The heart
Atrial fibrillation and MI are most common cause of emboli
Other causes: endocarditis, atrial myxoma, paradoxical venous emboli, rheumatic heart disease
Symptoms are more severe than with thrombotic occlusion
ACUTE ARTERIAL OCCLUSION
Thrombotic uutnumber embolic occurence by
6:1
ACUTE ARTERIAL OCCLUSION
Thrombi almost always occurs as a result of
Long standing atherosclerosis
Patients typically had chronic vessel occlusion
Associated with hypercoagulable states that disposes pts to thrombus formation
ACUTE ARTERIAL OCCLUSION: CLINICAL PICTURE
Clinical presentation is dependent on
subtotal obstruction that allows for the development of collateral circulation
In these pts, total occlusion will present with less symptoms
In pts w/o collateral circulation, the event has dramatic symptoms
![](https://s3.amazonaws.com/brainscape-prod/system/cm/274/667/334/a_image_thumb.png?1555533443)
ACUTE ARTERIAL OCCLUSION: CLINICAL PICTURE
Symptoms of Sudden onset of acute extremity ischemia include:
Pulselessness
Pain
Pallor
Paresthesia
Paralysis
These are the 5 Ps a/w acute ischemia!!!
Acute Ischemia of an extremity is an Emergency
Irreversible tissue damage will occur if not reversed w/in 4 - 6 hrs
![](https://s3.amazonaws.com/brainscape-prod/system/cm/274/667/638/a_image_thumb.png?1555533675)
ACUTE ARTERIAL OCCLUSION: CLINICAL PICTURE
Early manifestations of acute extremity ischemia:
Absence of pulses and pallor
ACUTE ARTERIAL OCCLUSION: CLINICAL PICTURE
Late manifestations of acute extremity ischemia:
Motor weakness and Paresthesia
ACUTE ARTERIAL OCCLUSION: CLINICAL PICTURE
Initial Management of acute ischemia:
Emergency
Requires Rapid evaluation and treatment
Immediate anticoagulation
<strong>T</strong>o prevent propagation of the thrombus => typically general anesthesia for this reason
Many will already taking an antiplatelet drug
Will still receive IV heparin upon arrival to the hospital
Immediate surgical revascularization
If thrombotic formation in non-atherosclerotic limb (No PVD but develop a thrombus) => femoral thromboembolectomy
Anticipate significant and acute blood loss with thrombectomy or embolectomy
If thrombotic formation in PVD limb (a thrombus forms in someone who has PVD) => arteriography to determine severity and anatomic location of the occlusion
Thrombolytic therapy in conjunction with both
ACUTE ARTERIAL OCCLUSION: CLINICAL PICTURE
Medical evaluation and cardiac testing warranted - why?
Perioperative M&M is high as most of these patients have several clinical risk factors
CHRONIC ARTERIAL OCCLUSION: CLINICAL PICTURE
Chronic PVD is caused by
atherosclerosis (plaque build up),
vessels become progressively narrowed by plaque
![](https://s3.amazonaws.com/brainscape-prod/system/cm/274/668/841/a_image_thumb.png?1555534584)
CHRONIC ARTERIAL OCCLUSION: CLINICAL PICTURE
Once diameter of the vessel is significantly narrowed, what typically occurs?
Thrombotic occlusion