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Cardiology - Dr Constable > Quiz 7 Endovascular Aortic Repair > Flashcards

Quiz 7 Endovascular Aortic Repair Flashcards

1
Q

What does TEVAR and EVAAR mean?

A

TEVAR - Thoracic Endovascular Aortic Repair

EVAAR - Endovascular abdominal aortic repair

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2
Q

What does the deployment of a graft require as far as a landing area for the aneurysm?

A

Requires landing zone of at least 1cm on both sides of the aneurysm.
**Book states proximal landing zone of 15mm and diameter no greater than the diameter of the largest available EV graft.

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3
Q

What was the problem with early tube grafts?

A

High failure rate due to under estimation of atheromatous disease in the aorto-iliac segments and distal aorta

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4
Q

What was the problem with Aorto-uni-illiac stent grafts?

A

caused occlusion of the contralateral iliac - which necessitated a fem-fem bypass

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5
Q

What is an advantage to the Modular Bifurcated Stent Graft?

A

Consists of 2 or 3 components - allows normal aorto-iliac anatomy to be preserved

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6
Q

What is a challenging problem with the Fenestrated stents?

A

Challenge to line up the holes with arterial openings.

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7
Q

To accomplish an EVAR, what is the determining factor on whether or not you can do this procedure?

A

This procedure is highly dependent on good access.

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8
Q

What are Branched Stent Grafts good for?

A

allows for preservation of the origins of vital arteries

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9
Q

Why would a retroperitoneal approach be utilized for Endo Grafting?

A

In cases where femoral vessels are too small or heavily calcified

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10
Q

What is the common site for retroperitoneal approach?

A

Distal Aorta or proximal iliac - a dacron graft/conduit will be sewn there

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11
Q

What is a hybrid approach to EVAR and when would that be ideal?

A

Combines both open surgical and endovascular stenting.

Ideal for cases where stenting would occlude major luminal branches.

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12
Q

If a person needs a TEVAR of the Left Subcalvian artery, you would know that they would also need ________-_______ bypass.

A

subclavian-carotid bypass before they have a TEVAR.

This is an example of a Hybrid procedure.

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13
Q

When doing a staged Elephant Trunk Procedure, What does Stage I consist of?

A

Total aortic arch replacement - open procedure

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14
Q

When doing a staged Elephant Trunk Procedure, what does Stage II consist of?

A

Endovascular repair - using the elephant trunk as the proximal landing zone

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15
Q

When doing a staged Elephant Trunk Procedure, is the pt circulatory system normothermic or hypothermic?

A

Requires Deep hypothermic circulatory arrest

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16
Q

Is Aortic Visceral Debranching an open, EVAR or hybrid procedure?

A

Hybrid - If aneurysm involves major visceral branches such as celiac, SMA, inferior messenteric vessels or renals - open revascularization of these vessels is undertaken simultaneously or immediately prior to Endo Stenting

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17
Q

What are your indications for EVAR?

A
  • Elective repair for AAA > 5 cm or growing > 1cm/yr
  • Elective repair for TAA > 5.5cm or growing > 3cm/yr
  • Symptomatic aneurysms - hoarseness/cough for stimulation of RLN
  • Significant Co-morbidities due to increased risk of open procedure
  • Traumatic Aortic injuries
  • Stanford Type B dissections: Involve aorta distal to the origin of the L Subclavian artery
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18
Q

What is the Stanford Classification system for aneurysm?

A

Easy way to classify an aneurysm.

  • Class A - Involve the ascending aorta and are urgent or emergent cases
  • Class B - aorta distal to subclavian arteries
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19
Q

What are the eligibility requirements, as far as aneurysm neck (proximal landing zone) size for grafting?

A

Length > 15mm
Diameter < 30mm
Angulation < 60 degrees long axis
Thrombus < 2mm layer of mural thrombus

20
Q

Should the Iliac Arteries need to be free of aneurysm in order to have EVAR?

A

yes, and they should also be free of occlusive disease. The same goes for whatever arteries will be used for access.

21
Q

Can an EVAR be done as a MAC case?

A

Yes but the pt must be able to lay supine for 1-2 hrs

22
Q

What are some benefits to using Central Neuraxial Blockade for EVAR?

A

No need for TEE
No need for MEP or SSEP
No need for measures to achieve a motionless field during stent deployment

23
Q

When would a General anesthetic be the better choice for EVAR?

A
  • Complicated EVAR (fenestrated or branched)
  • need for iliac access
  • planned use of TEE
  • planned hemodynamic manipulations to create a motionless field
  • Planned SSEP and/or MEP monitoring
  • Hx of difficult airway
24
Q

What are the goals to anesthetic management of EVAR?

A
  • Maintain hemodynamic stability
  • Avoid hypertension and tachycardia
  • maintain intravascular volume and early identification/management of bleeding
25
Q

What factors increase the risk of Acute Kidney Injury during EVAR?

A
  • hypoperfusion
  • Stent graft material covering the renal vessels
  • emboli to the renal arteries
  • Contrast induced nephropathy
26
Q

How can you avoid Acute Kidney injury during EVAR?

A
  • perioperative euvolemia
  • maintain CO and BP
  • limit contrast dye exposure
  • use iso-osmolar non-ionic contrast dye
  • may use pharmacologic strategies in pts with baseline kidney disease (N-acetylcysteine, NaHCO3, Statin drugs)
27
Q

If during an EVAR, the pt experiences significant or severe hypotension, what is likely the cause?

A

rupture or bleeding from a vessel

28
Q

What are the factors involved with Spinal Cord Perfusion Pressure?

A

SCPP = MAP - CSF pressure

To increase SCPP you would increase the pt’s MAP or decrease their CSF.

29
Q

What is the artery of Adamkiewicz? Where does it feed from?

A

Anterior spinal artery - largest is the artery of Adamkiewicz arises from the aorta at T9 - T-12 but can come from as high as T5 to as low as L5

30
Q

When will someone undergoing EVAR or TEVAR likely have SSEP and MEP monitoring?

A

When there is a high risk for post-op paraplegia

- allows for ID of ischemic changes immediately and allows for rapid intervention (ie increase MAP or decrease CSF)

31
Q

When would TEE be used during EVAR?

A
  • To help diagnose and confirm aortic pathology
  • ID guidewire, sheath, and endograft location
  • detect endoleaks
  • cardiac assessment
32
Q

If someone has already had a previous AAA repair, what would be a concern?

A

May have already compromised collateral circulation to the spinal cord - may have already sacrificed the IMA or median sacral artery

33
Q

If your pt develops paraplegia following TEVAR, what should be done?

A
  • Elevate MAP > 80 mmHg
  • CSF drain
  • repeat neuro exams for evidence of reversal of paraplegia
  • Avoid abrupt cessation of CSF drainage
34
Q

After deployement of an endograft, blood flow should be _____________ through the aorta. During TEVAR the surgeon will need a _________ _______ since the graft will be near major vessels. Migration of a thoracic graft would be ____________.

A

reduced
Motionless field
Catastrophic

35
Q

What are some early complications following EVAR?

A
  • Ileofemoral lacerations,
  • AKI,
  • pelvic and LE ischemia,
  • MI,
  • paraplegia,
  • Stroke
36
Q

What is post-implantation syndrome?

A
  • Fever,
  • leukocytosis,
  • elevation of inflammatory mediators (CRP, IL 6, TNF, etc)
37
Q

What are some late complications following EVAR?

A
  • Device migration,
  • endoleaks with aneurysm rupture, -endograft infection,
  • long term effects of radiation exposure.
38
Q

What is an endoleak type I?

A

Involves the proximal or distal seal zone. May require further ballooning or placement of another graft

39
Q

What is an endoleak type II?

A

due to retrograde flow from the intercostals

40
Q

What is an endoleak type III?

A

occurs with inadequate overlap and seal between modular componenets

41
Q

What is an endoleak type IV?

A

occurs due to porosity of graft (rare in modern grafts)

42
Q

What is an endoleak type V?

A

endotension - continued sac extension with no identifiable source

43
Q

If a crossclamp needs to be performed, what is the most amount of time it can be clamped without the likelihood of paraplegia?

A

15 minutes

44
Q

What are some indications for placing a CSF drain for EVAR?

A

Involvement of T9-T12 (artery of Adamkiewicz)
involvement of arch vessels (origin of ant spine artery)
Previous TAA or AAA
Symptomatic spinal ischemia

45
Q

After EVAR, you may anticipate hypovolemia and lactic acidosis secondary to…?

A
  • Reperfusion of lower extremities
  • visceral ischemia during branched stent graft introduction
  • reperfusion syndrome following EVAR of Type B dissection
46
Q

What are some cardiogenic considerations during EVAR?

A
  • perioperative MI
  • guide wire manipulation near aortic arch (baroreceptors) –> arrhythmias
  • cardiac tamponade from hemoparicardium from over advancement of guidewire.

Cardiology - Dr Constable (9 decks)

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