PVD reduced

Question 1

What is PVD

Answer 1

1. Compromised blood flow to the extremities
2. Ankle-brachial index of less than 0.9
   
   • Ratio of SBP in ankle vs SBP in brachial artery

Question 2

What causes PVD

Answer 2

1. Atherosclerosis- most common cause
   
   • goes hand in hand with CAD
2. Arterial embolism- acute cause
3. Vasculitis - inflam of vasculature

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 y.o. (exceeds 70%)

Question 4

Atherosclerosis risk factors

Answer 4

1. DM
2. Obesity/Inactivity
3. Advanced age
4. Male gender
5. Family Hx of early atherosclerosis
6. HTN
7. HLD
8. Smoking
9. Hyper-homo-cystein-emia

Question 5

Atherosclerosis s/s

Answer 5

1. Intermittent claudication → most common symptom
   
   • _{pain that starts with walking/exercise and <strong>stops with rest</strong>}
2. cool/cold feet or leg pain while lying flat
   
   • _{relieved by sitting}
   • _{sign of advanced disease}
3. loss of pulses in feet/legs
4. pale color in legs when raised
   
   • _{<strong>dependent</strong> <strong>rubor</strong> - redness in dependent position}
5. shiny skin
6. loss of hair on feet
7. thinckened toenails→may have fungal infection
8. critical limb ischemia
   
   • _{Most severe symptom}
   • _{“rest pain”}
   • _{lack of O2 to the limb at rest}
   • _{associated with non-healing ulcers & gangrene}

Question 6

Diagnostic tests for atherosclerosis

Answer 6

1. Duplex and Doppler Ultrasonography
   
   • measures lamilar flow it is either red = towards probe, blue = away
2. Ankle/Brachial Index
   
   • Normal index is 0.95 at rest
   • < 0.9 = claudication
   • < 0.4 = pain with resting
   • < 0.25 = ischemic ulceration or impending gangrene
3. Transcutaneous oximetry
   
   • 60 mm/Hg = Normal
   • < 40 mmHg in patients with limb ischemia
4. MRI
5. Contrast angiography - locates blocked area

Question 7

atherosclerosis treatment

Answer 7

1. LIfestyle modification
   
   • exercise, weight loss, smoking cessation
2. Lipid-lowering medications
   
   • statin drugs
3. Vitamin C, E, folate
4. Antiplatelet therapy
5. Revascularization
   
   • PTA w/stent, Bypass, Intra-arterial thrombolytic therapy, balloon embolectomy, endarterectomy
6. Amputation :-(

Question 8

Surgical approach to Peripheral Revascularization

Answer 8

• Donor and Recipient arteries are exposed and a tunnel is created for a bipass graft
• Graft either Saphenous vein or prosthesis
• Heparin given IV
  
  • must note the time (3-5 min onset)
  • Still able to use regional anesthesia (dose 3000-5000)
• Anastamosis is made
• Arteriogram to confirm flow
• Heparin is usually NOT reversed

Question 9

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

Answer 9

Phenylephrine

Don’t get sent home for the day.

Question 10

PVD

Anesthetitc risks and considerations

Answer 10

1. Principal risk - athlerrosclerosis and ischemic heart disease (manage like they have CAD)
   
   • AVOID hypo/hypertension
   • AVOID tachycardia
2. Patients with PVD have 3-5x greater risk of stroke, MI and death
3. To reduce risks of revascularization suregery:
   
   • Patents who experience angina and claudication will get a CABG prior to revascularization surgery

Question 11

Risks with revascularization

Answer 11

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

Question 12

peripheral revascularization

Pre-op meds and Monitoring

Answer 12

• Preop → make sure pt takes beta-blockers and/or other chronic medication
• Intra-op monitoring→ Consider co-morbidities _{(<strong>CAD</strong>, <strong>diabetes</strong>, <strong>HTN)</strong>}
  1. Fluid and volume status
     
     • A-line + CVP or foley to monitor fluid volume status/end organ profusion
     • Estimate blood loss and 3^rd space fluid loss
     • Pulse ox oxygenation
  2. Follow Blood Gasses + coags + electrolytes
  3. Note Cross-clamp time _{(limb ischemia time)}
  4. Note when heparin is given_{(peaks in <strong>3-5</strong>min)}

Question 13

peripheral revascularization

Anesthetic management

Answer 13

​Regional is preferred (spinal > epidural = less hematoma risk)

• Increased graft blood flow (grafts do better)
  
  • spinal is preferred - less hematoma risk
• Less increase in SVR with cross-clamping (sympatectomy)
• Better Postop pain relief (​less SNS outflow and less vasoconstriction)
• Less activation of the coagulation system
  
  • less risk of grafts clotting and having to return to the OR
  • decreased SNS outflow = less inflammation
• ​Make sure to check INR and platelets prior to regional
• There is NO difference if CV complications with regional vs GA
  
  • ​BUT there is a SIGNIFICANT difference in complication rate of GRAFT OCCLUSIONS
  • General hage an increased risk of occlusions!!!

Question 14

In revascularization which is prefered, spinal or epidural?

Answer 14

Spinal

higher risk of hematoma with epidural

Question 15

What advantage has been shown with regional vs general in revascularization

Answer 15

Regional has improved outcomes for graft occlusion, and post op pain management

…but shows no benefit in terms of cardiopulmonary complications

Question 16

PVD

Regional vs. General?

Answer 16

• Assess for coagulopathy
• General is indicated for pts in which heparin therapy has already been started
• Regional is a good consideration b/c:
  
  • _{has <strong>lower</strong> incidence of post-op graft occlusion, r/t <strong>↓SNS outflow</strong>}
    
    • _{vasodilation, ↓circulating catecholamines, and ↓ blood viscosity r/t fluid volume loading}
  • _{If considering regional, <strong>spinal</strong> may be better choice over epidural to avoid <strong>hematoma</strong> (much smaller needle)}
  • _{Studies have shown <strong>no difference</strong> btw RA & GA in terms of cardiopulmonary complications}
• Monitoring
  
  • _{pt’s present w/other co-morbidities (CAD,DM,HTN)-degree of monitoring depends on sx & extent of dz}
  • _{Consider use of <strong>a-line</strong>}
    
    • _{good documentation that an assessment of collateral flow has been performed esp w/co-existing microvascular disease such as Reynaud’s}
  • _{<strong>consider need to monitor intravascular volume</strong>}
    
    • _{<strong>CVP</strong>, <strong>Swan</strong>, or simply via <strong>foley</strong> - the “<strong>poor man’s Swan</strong>”}
  • _{Initial revascularization procedures generally have minimal blood loss & minimal third space loss}
• Pre-op
  
  • _{make sure pt’s take <strong>beta</strong> <strong>blockers</strong> or other chronic meds such as antihypertensives (except ACE-inhibs)}
• Post-op
  
  • _{provide adequate analgesia to <strong>prevent ↑SNS stim</strong> & therefore maintain graft patency}
  • _{can use <strong>Precidex</strong> (dexmedetomidine) an alpha-2 agonist to <strong>attenuate ↑HR & NE r</strong>elease during emergence or extubation (less sedating than propofol but can cause marked hypotension & bradycardia) Dose = 0.2-0.7 mcg/kg IV}