PVD

Question 1

What is PVD

Answer 1

Compromised blood flow to the extremities

Question 2

What causes PVD

Answer 2

Atherosclerosis- most common cause

Arterial embolism- acute cause

Vasculitis

Question 3

Is someone has PVD, it can be assumed that they likely have

Over what age can it be assumed that someone has PVD

Answer 3

CAD

Over 75 (exceeds 70%)

Question 4

How many Americans have symptomatic PVD

Answer 4

2 million

Question 5

Progression of atherosclerotic lesions

Answer 5

Fibrous plaque–> calcium accumulation–> Endothelium disruption–> platelet thrombus formation–> hemorrhage into lesion

Question 6

Atherosclerosis risk factors

Answer 6

DM
Advanced age
Male gender
Obesity/Inactivity
HTN
Smoking
HLD
Hyperhomocysteinemia
Family Hx of early atherosclerosis

Question 7

Atherosclerosis s/s

Answer 7

Intermittent claudication- most common symptom

cool/cold feet
leg pain while lying flat, relieved by sitting
loss of pulses in feet/legs
pale color in legs when raised
dependent rubor
shiny skin
loss of hair on feet
Thickened toenail

Most severe symptom- critical limb ischemia

Question 8

Diagnostic tests for atherosclerosis

Answer 8

Doppler

ABI- normal index .95, <40 indicates skin ischemia

Contrast angiography is the gold standard and often carried out prior to any surgery

Question 9

Tx atherosclerosis

Answer 9

LIfestyle modification- exercise, weight loss, smoking cessation

Lipid-lowering medications

Vitamin C, E, folate

Antiplatelet therapy

Revascularization- PTA w/stent, Bypass, Intra-arterial thrombolytic therapy, balloon embolectomy, endarterectomy

Amputation :-(

Question 10

Indications for revascularization

Answer 10

Acute ischemia due to emboli, thrombus, pseudoaneurysm from femoral a-line. Must be corrected within 4-6 hours to prevent ischemia/infarct.

Chronic ischemia from plaque progressing to claudication

Question 11

Giving what drug during revascularization will likely get you sent home for the day

Answer 11

Phenylephrine.

Don’t get sent home for the day.

Question 12

Does heparinization during revascularization preclude the use of regional anesthesia?

Answer 12

Usually still OK as only 3000-5000 units will be given during the procedure

Question 13

What is the primary risk during revascularizatiom

Answer 13

3-5x greater risk of MI, stoke, and death in a pt with atherosclerosis

Question 14

Anesthetic management for a pt with PVD

Answer 14

Treat it like CAD, which they probably also have. No hypo/hypertension, no tachycardia

Risk can be reduced if pt has already had a CABG to treat CAD

Question 15

Risks with revascularization

Answer 15

Hemorrhage
Infection
Pulmonary embolism (watch ETCO2)
MI
Low CO--> ischemia 
Pulmonary edema
Risks associated with the lithotomy position- nerve palsy, limb ischemia

Question 16

Monitoring consideration for revascularization

Answer 16

A-line, intra-op ok
CVP or foley to monitor fluid volume status

Watch coags, electrolytes, and pH changes

Cross-clamp heparin admin- make sure to note time of admin. Heparin peaks in 3-5min.

Question 17

Benefits of regional in revascularization

Answer 17

Increased graft blood flow

Less increase in SVR with cross-clamping

Postop pain relief

Less activation of the coag system

Question 18

In revascularization which is prefered, spinal or epidural?

Answer 18

Spinal, higher risk of hematoma with epidural

Question 19

What advantage has been shown with regional vs general in revascularization

Answer 19

Regional has improved outcomes for graft occlusion, but shows no benefit in terms of cardiopulmonary complications