PVD Flashcards

1
Q

What is PVD?

A

Compromised blood flow to the extremities

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2
Q

What causes PVD?

A

1) Atherosclerosis** (chronic problem)
2) Arterial embolism (acute problem)
- Emboli may originate from heart, abdominal aorta, or femoral artery
3) Vasculitis
- Inflammation of the walls of the BVs

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3
Q

Common arteries for athersclerotic plaques

A

Distal abdominal aorta
Iliac arteries
Subclavian arteries
Coronaries

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4
Q

If your patient has PVD, what should you also assume?

A

They have CAD.

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5
Q

Over __% of people over 75 have atherosclerosis

A

Over 70%

Thus for everyone over 75, assume they have PVD, and thusly also assume that they have CAD

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6
Q

Risk factors for atherosclerosis

A
DM
Essential HTN
Hyperlipidemia
Smoking
Aging
Men
Obesity and physical inactivity
Sedentary lifestyle
Family hx of premature atherosclerosis
Hyperhomocysteinemia (high levels of homocystein predispose people to endothelial damage)
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7
Q

What is intermittent claudication?

A

Angina of the legs!
Pain and limping when walking or exercising. Pain is experienced in the calf, thigh, or buttock, and is relieved with rest.

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8
Q

S/S of PVD

A

Intermittent claudication**
Feet are cold to the touch
Pain in legs when lying flat, and relieved by a sitting position
Weak or absent pulses in legs/feet
Pallor when legs are raised
Dependent rubor (redness in legs when in a dependent position)
- Shiny skin
- Loss of hair
- Thickened toenails (may have fungal infection)

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9
Q

What is the most severe symptom of PVD?

A

Critical limb ischemia (CLI)

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10
Q

What is critical limb ischemia (CLI)?

A

Extreme form of intermittent claudication

  • Pain in legs at rest
  • Blood flow is so diminished that even basic metabolic demands are not met
  • Associated with non-healing ulcers and gangrene
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11
Q

Diagnostic tests for PVD/atherosclerosis

A
Doppler U/S
Ankle/Brachial Index
Duplex Ultrasonographic Scan
Transcutaneous Oximetry
- Test to measure oxygen content in the tissues
- Normal is 60mmHg
- < 40mmHg = skin ischemia
MRI
Angio with contrast
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12
Q

What is the ankle/brachial index?

A

Ratio of the BP in the lower legs to BP in the arms
Normal is .95
< .9 = claudication
< .4 = Pain at rest (CLI)
< .25 = ischemic ulceration or impending gangrene

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13
Q

Goals of treating PVD

A

Improve functional status
Prevent stroke
Prevent limb loss
Reduce potential atherosclerotic progression and cardiovascular morbidity

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14
Q

How to treat PVD

A
Treat risk factors the patient has (lifestyle changes)
Lipid-loweing therapy (statins)
Vitamin C and E supplements
Anti-plt therapy
Revascularization procedures
Amputation
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15
Q

Revascularization procedures we may see our patients for

A
  • Percutaneous transluminal angioplasty (PTA) with possible stent placement
  • Bypass surgeries
  • Intra-arterial thrombolytic therapies
  • Balloon-catheter embolectomy
  • Endarterectomy
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16
Q

Indications for revascularization procedures

A

1) Acute ischemia
- Emboli
- Thrombi
- Pseudoaneurysm from previous fem a-line
- Ischemia within 4-6 hours post-op

2) Chronic Ischemia
- Atherosclerosis that causes claudication

17
Q

Patients presenting for revascularization procedures were probably given ____ overnight

A

Heparin
Surgeons don’t want the vessels to clot
Studies show that regional blockade if best for these patients (be aware of coagulopathy)

18
Q

Description of peripheral revascularization surgery

A

1) Donor and recipient arteries are exposed, tunnel is created and graft is passed
2) Graft may be saphenous vein or prosthesis
3) Heparin and papaverdin are given IV
4) Do NOT give phenylephrine in these cases, as it will directly oppose the actions of papaverdin
5) Anastomoses are constructed
6) Arteriogram and doppler to assess flow and quality of pulses
7) Heparin probably won’t be reversed to prevent clotting of the new graft

19
Q

Anesthetic considerations for the person with PVD

A

1) Always assume they have CAD!! Pt with PVD has a 3-5x greater risk of MI, stroke, and death.
- No long periods of hyper or hypotension or tachycardia!!

2) CABG operations are usually performed before surgery on the peripehral vasculature in pts who experience angina and claudication

20
Q

You should always assume that someone with PVD has ____ unless _____

A

CAD

Unless they had a CABG

21
Q

Risks of revascularization surgeries

A

Hemorrhage and infection (like every surgery ever)
PE (clot may become dislodged)
Cardiac complications (from assumed CAD)
- MI, low CO, pulmonary edema
Ischemia of the lower extremities if lithotomy position is used

22
Q

Monitoring for peripheral re-vascularization

A

5-Lead EKG
A-line
Ability to monitor intravascular volume with CVP, CO, or foley

23
Q

Benefits of RA vs. GA for revascularization (vascular grafting)

A

1) Increased graft blood flow
- lower incidence of graft occlusion
2) Less increase in SVR with cross-clamping
3) Better post-op pain relief
4) Less activation of the coagulation system
5) No difference in cardiopulmonary complications between RA and GA
6) Sympathectomy makes it easier for the surgeons

Even with RA, we do a balanced technique with propofol (sedation)

24
Q

Method of RA preferred for peripheral revascularization

A

Spinal

Remember that the patient will be heparinized, so they’re at higher risk for epidural bleed if we place it here

25
Q

If your patient has coagulopathy, should you do RA or GA?

A

GA, bitch.

26
Q

Make sure to make note of the time that this happens during a revascularization case

A

Time heparin is given.

Heparin peaks in 3-5 minutes, and this is when they’ll start doing shit.