Spring 2024 (Exam III) Vascular Disease Assessment Flashcards
What is an aortic aneurysm?
An aortic aneurysm is a bulge in a section of the aorta caused by an underlying weakness in the aortic wall.
How are aortic dissections classified according to the DeBakey and Stanford systems?
The DeBakey system classifies aortic dissections into
- Type I (tear in the ascending aorta that propagates to the arch),
- Type II (tear confined to the ascending aorta), and
- Type III (tear in the descending aorta).
The Stanford system classifies them as
- Type A (tear in the ascending aorta) and
- Type B (tear in the descending aorta).
What is the treatment approach for ascending arch dissections?
Ascending arch dissections typically require emergent surgery.
How are descending arch dissections typically treated?
Descending arch dissections are rarely treated with urgent surgery.
What is the initial treatment for uncomplicated type B aortic dissections?
Uncomplicated type B dissections are often admitted for Blood pressure control, with short-acting beta-blockers being preferred, along with arterial line monitoring.
What symptoms indicate an impending rupture of an aortic dissection, and what is the treatment?
Symptoms of impending rupture include
posterior pain, hypotension,
left- side hemothorax,
ischemia of the legs, abd, spinal cord
renal failure
which indicate the need for surgical treatment.
What are the risk factors for aortic aneurysms and dissections?
Risk factors include hypertension (HTN), atherosclerosis, age, being male, smoking, and family history.
Which inherited disorders are associated with aortic aneurysms and dissections?
Inherited disorders associated with these conditions include Marfan’s syndrome, Ehlers-Danlos syndrome, bicuspid aortic valve, and non-syndrome familial history.
What are some causes of aortic dissection?
Causes of dissection include blunt trauma, cocaine use, and iatrogenic causes (caused by medical treatment).
What iatrogenic causes are related to aortic dissections?
cardiac catheterization,
aortic manipulation,
cross-clamping
arterial incision.
Who is more commonly affected by aortic dissections?
Aortic dissection is more common in men and pregnant women in their third trimester.
What are the three main arterial pathologies in vascular disease?
The three main arterial pathologies are aneurysms, dissections, and occlusions.
Which vessels are more likely to be affected by aneurysms and dissections?
The aorta and its branches are more likely to be affected by aneurysms and dissections.
Which arteries are more likely to be affected by occlusions?
Peripheral arteries are more likely to be affected by occlusions.
An aortic aneurysm is defined as the dilation of all three layers of an artery, with a greater than ____increase in diameter
than 50% increase in diameter
What symptoms might be present with an aortic aneurysm?
asymptomatic or due to compression of surrounding structures.
How are aortic aneurysms initially treated?
surgery indicated for?
what is preferred over open surgery?
Avoid strenuous exercise, stimulants, stress
Surgery indicated if >5.5 cm, growth >10mm/yr, family h/o dissection
Endovascular stent repair has become a mainstay over open surgery w/graft
What is the mortality rate associated with a ruptured aortic aneurysm?
The mortality rate for a ruptured aortic aneurysm is approximately 75%.
What are the two types of aortic aneurysms?
The two types of aortic aneurysms are fusiform and saccular.
What is the fastest and safest measure for obtaining a diagnosis of suspected aortic dissection?
Doppler echocardiogram
How does mortality rate change over time with an aortic dissection?
The mortality rate increases by 1-2% per hour.
What is the overall mortality rate for aortic dissection?
The overall mortality rate for aortic dissection is 27-58%.
How is aortic dissection diagnosed in stable and unstable patients?
In stable patients, diagnosis can be made with CT, chest X-ray (CXR), MRI, or angiography. In unstable patients, echocardiography is used.
What are some causes of aortic dissection?
Causes include blunt trauma, cocaine use, and iatrogenic factors resulting from medical treatment.
Who is more likely to experience an aortic dissection?
men
pregnant women during the third trimester.
What are the four primary causes of mortality related to surgeries of the thoracic aorta?
(MI),
respiratory failure,
renal failure,
stroke.
In Stanford A dissection
With current techniques, a period of circulatory arrest of ___ at a body temperature of ___ can be tolerated by most patients
of 30-40 minutes at a body temperature of 15-18°C can be tolerated by mostpatients
Pts with an acute, but uncomplicated type B aortic dissection who have ____________ can be treated with medical therapy
who have normal hemodynamics,
no periaortic hematoma,
no branch vessel involvement
Stanford B dissection mortality rate?
distal aortic dissection mortality rate?
10%
30%
A triad of sxis experienced in about ½ of cases for aortic aneurysm rupture?
Hypotension
Back pain
A pulsatile abdominal mass
Most abdominal aortic aneurysms rupture into
left retroperitoneum
Euvolemic resuscitation may be deferred until aortic aneurysm rupture is surgically controlled bc?
resulting increase in blood pressure without control of bleeding may lead to
loss of retroperitoneal tamponade,
further bleeding,
hypotension,
and death
major complications associated with replacement of the aortic arch
Neurologic deficits
4 Primary causes of mortality r/t surgeries of thoracic aorta:
MI
Respiratory failure
Renal failure
Stroke
What should be assessed for in the preoperative evaluation for thoracic aorta surgery?
Assess for the presence of
coronary artery disease,
valve dysfunction
and heart failure.
What are some cardiac evaluation tests used in the preoperative phase?
Cardiac evaluation tests can include stress testing, echocardiography, and radionuclide imaging.
Why might a patient be precluded from an abdominal aortic aneurysm (AAA) resection in preop phase?
A severe reduction in (FEV1) or renal failure may preclude a patient from AAA resection.
What are predictors of post-aortic surgery respiratory failure?
Smoking and (COPD)
What preoperative interventions might be considered for patients at risk of respiratory complications?
PFTs & ABGs help define risk
Consider bronchodilators, antibiotics, and CPT
What is the most important indicator of post-aortic surgery renal failure?
Preoperative renal dysfunction is the most important indicator of post-aortic surgery renal failure.
What are key preoperative management steps to mitigate renal failure risk in aortic surgery?
Key steps include ensuring preoperative hydration, avoiding hypovolemia, hypotension, low cardiac output, and nephrotoxic drugs.
What vascular evaluation should be done for pt w/ hx of stroke or (TIA)?
a carotid ultrasound
angiogram of brachiocephalic and intracranial arteries should be performed.
Anterior spinal artery syndrome is caused
by lack of blood flow to the anterior spinal artery
The anterior spinal artery is responsible for perfusing?
ischemia of the area leads to ?
the anterior 2/3 of the spinal cord
Ischemia of this area leads to:
- loss motor function below the infarct
- diminished pain and temperature sensation below the infarct
- autonomic dysfunction leading to hypotension and loss of bowel & bladder function
What should be considered if severe carotid stenosis is identified before elective aortic surgery?
If severe carotid stenosis is identified, consideration should be given to carotid endarterectomy (CEA) before elective surgery.
What is a cerebral vascular accident (CVA)?
A CVA, also known as a stroke, can be ischemic (87% of cases) or hemorrhagic (13%) and is characterized by sudden-onset neurological deficits.
Where does CVA rank in leading causes of disability and death in the U.S.?
CVA is the first leading cause of disability and the third leading cause of death in the U.S.
What is a transient ischemic attack (TIA)?
A TIA is a subset of ischemic strokes that are self-limited, with symptoms resolving within 24 hours.
What is the risk of subsequent stroke after a TIA?
TIAs carry a risk that is 10 times greater for a subsequent stroke.
What can angiography diagnose in carotid disease?
Angiography can diagnose vascular occlusion.
What can CT and MRI reveal in carotid disease?
identify aneurysms and (AVMs).
How is transcranial Doppler ultrasound useful in carotid disease?
may give indirect evidence of vascular occlusions with real-time bedside monitoring.
What can carotid auscultation detect?
Carotid auscultation can identify bruits, which are sounds indicative of turbulent blood flow due to narrowing or blockage.
What information does carotid ultrasound provide?
Carotid ultrasound can quantify the degree of carotid stenosis.
Where does carotid stenosis commonly occur and why?
Carotid stenosis commonly occurs at the internal/external carotid bifurcation due to turbulent blood flow at the branch-point.
What should the workup for carotid disease include?
The workup should include evaluation for sources of emboli such as atrial fibrillation, heart failure, valvular vegetation, or paradoxical emboli in the setting of a patent foramen ovale (PFO).
What does the American Heart Association recommend for the treatment of CVA?
The American Heart Association recommends tissue plasminogen activator (TPA) within 4.5 hours.
How long after the onset of CVA can intravascular thrombectomy be beneficial?
Benefits of intravascular thrombectomy have been seen up to 8 hours after the onset of CVA.
severe carotid stenosis is?
typically for blockages >70%
lumen diameter 1.5mm
What is an alternative treatment to Carotid Endarterectomy?
Carotid stenting is an alternative to CEA.
What is a major risk associated with carotid stenting?
The major risk associated with carotid stenting is microembolization leading to CVA.
In CEA preop eval, you must maintain?
collateral blood flow through stenotic vessels, esp during cross-clamp to prevent ischemia
avoid extreme head rotation
what to do when a patient has severe carotid disease and severe coronary artery disease?
The dilemma is to stage cardiac revascularization and CEA appropriately, prioritizing the most compromised area.
What factors affect cerebral oxygenation as monitored by cerebral oximetry?
- Mean arterial pressure (MAP)
- Cardiac output (COP)
- Oxygen saturation (SaO2)
- Hemoglobin (HGB)
- (PaCO2).
Cerebral 02 consumption effected by:
temperature
anesthesia
What are common causes of cardiogenic embolism leading to artery occlusion?
Common causes include a left atrial (LA) thrombus arising from atrial fibrillation and a left ventricular (LV) thrombus from dilated cardiomyopathy post-myocardial infarction.
What are some less common thrombus causes for acute artery occlusion?
Less common thrombus causes include valvular heart disease, endocarditis, and a patent foramen ovale (PFO).
What are noncardiac causes of acute artery occlusion?
Noncardiac causes include atheroemboli, plaque rupture, hypercoagulability, and trauma.
How is acute artery occlusion diagnosed?
tx?
arteriography.
Treatments include surgical embolectomy, anticoagulation, and amputation as a last resort.
How is peripheral artery disease defined in terms of the ankle-brachial index (ABI)?
ankle-brachial index (ABI) of less than 0.9.
What is the ankle-brachial index (ABI)?
The ABI is the ratio of the systolic blood pressure (SBP) at the ankle to the SBP at the brachial artery.
typical cause of chronic hypo-perfusion in PAD?
typical causes of acute?
typically due to atherosclerosis, but may also be caused by vasculitis.
acute: embolism
How does the incidence of PAD change with age?
increases w/ age exceeding 70% by 75 yrs old
Pts w/ PAD have ____ risk of MI and CVA
patients with PAD have a 3-5 times higher risk of (MI) and (CVA).
What are common signs and symptoms of peripheral artery disease/ acute artery occlusion?
- Intermittent claudication,
- Resting extremity pain,
- Decreased pulses,
- Subcutaneous atrophy,
- Hair loss, coolness, and
- Cyanosis.
*Relief w/hanging LE over side of bed (↑hydrostatic pressure)
What is Doppler ultrasound used for in PAD?
Doppler ultrasound with pulse volume waveform identifies arterial stenosis in PAD.
How does duplex ultrasound help in PAD?
Duplex ultrasound can identify areas of plaque formation and calcification in PAD.
What does transcutaneous oximetry assess in PAD?
can assess the severity of tissue ischemia in PAD.
When is MRI with contrast angiography used in PAD?
used to guide endovascular intervention or surgical bypass in PAD.
treatment for PAD?
Medical treatment for PAD includes exercise, blood pressure control, cholesterol control, and glucose control.
Revascularization is indicated in PAD with disabling claudication or ischemia.
Surgical options for PAD include arterial bypass procedures.
Endovascular repairs in PAD include transluminal angioplasty and stent placement.
What is Subclavian Steal Syndrome?
occurs when the subclavian artery is occluded proximal to the vertebral artery, causing blood flow in the vertebral artery to be diverted away from the brainstem.
What are the symptoms of Subclavian Steal Syndrome?
Symptoms include syncope, vertigo, ataxia, hemiplegia, and ipsilateral arm ischemia.
Effected arm SBP may be ̴20mmhg lower
Bruit over SCA
How is Subclavian Steal Syndrome treated?
risk factors?
SC endarterectomy is curative
Atherosclerosis, Takayasu Arteritis, aortic surgery
What is Raynaud’s phenomenon?
which gender effected more?
appears with?
episodic vasospastic ischemia of the digits
Effects women > men
May appear with CREST syndrome (scleroderma subtype)
What are some secondary causes of Raynaud’s phenomenon?
Secondary causes include:
- Connective tissue diseases like systemic sclerosis,
- Mixed connective tissue disease (MCTD),
- Systemic lupus erythematosus (SLE),
- Drugs and toxic agents,
- Endocrine diseases,
- Trauma or lesions of the great vessels,
- Arterial diseases,
- Hematologic disorders, and neoplasias.
What are the symptoms of Raynaud’s phenomenon?
Symptoms include digital blanching or cyanosis with cold exposure or sympathetic nervous system activation.
Raynaud tx
protection from cold, calcium channel blockers (CCBs), alpha-blockers, and surgical sympathectomy for severe ischemia.
superficial thrombophlebitis,
deep vein thrombosis (DVT)
chronic venous insufficiency.
Why is deep vein thrombosis (DVT) a major concern in the perioperative setting?
DVT is a major concern because it can lead to pulmonary embolism (PE), which is a leading cause of perioperative morbidity and mortality.
What is Virchow’s Triad?
factors that predispose to venous thrombosis:
venous stasis
hypercoagulability
disrupted vascular endothelium.
rx factors for thromboembolism
recent surgery,
trauma,
lack of ambulation,
pregnancy,
low cardiac output from congestive heart failure or myocardial infarction,
stroke, and
varicose veins.
Factors contributing to a hypercoagulable state include
- Estrogen therapy
- Surgery
- Cancer
- Deficiencies of endogenous anticoagulants like antithrombin III,Protein C,Protein S
- Stress response associated with surgery
- Inflammatory bowel disease
- History of previous thromboembolism
- Morbid obesity
- Advanced age
occur in approximately 50% of total hip replacements.
Normally subclinical and completely resolves
s/s extremity pain and swelling.
Risk factors for DVT
include age over 40,
surgery lasting more than 1 hour,
cancer,
orthopedic surgeries on the pelvis and lower extremities,
and abdominal surgery.
Doppler ultrasound is sensitive for detecting proximal thrombosis over distal thrombosis.
Venography and impedance plethysmography are also useful diagnostic tools.
prophylactic measures superficial thrombophlebitis and DVT in surgical patients?
(SCDs) and subcutaneous heparin injections 2-3 times a day.
Regional anesthesia can greatly ↓risk d/t earlier postop ambulation
longer HL & more predictable dose response
doesn’t require serial assessment of activated PTT
Less risk of bleeding
What are the disadvantages of using LMWH for DVT treatment?
Higher cost
Lack of reversal agent
Warfarin (vit K antagonist) is initiated during heparin treatment and adjusted to achieve ______
_____discontinued when Warfarin achieves therapeutic effect
_______continued 6 months or longer
______ may be placed in pts w/ recurrent PE, or have contraindication to anticoagulants
INR 2-3
Heparin
PO anticoagulants
An IVC filter
What is temporal (giant cell) arteritis?
Temporal arteritis is inflammation of the arteries of the head and neck.
What are the symptoms of temporal arteritis?
unilateral headache, scalp tenderness, and jaw claudication.
Opthalmic Arterial branches may lead to ischemic optic neuritis and unilateral blindness
Prompt initiation of corticosteroids is indicated for visual symptoms and to prevent blindness.
Biopsy of temporal artery shows arteritis in 90% of pts
What is Thromboangiitis Obliterans, also known as Buerger’s Disease?
inflammatory vasculitis that leads to small and medium vessel occlusions in the extremities.
Autoimmune response triggered by nicotine
Tobacco use is most predisposing factor
Most prevalent in men <45
What are the diagnostic criteria for Thromboangiitis Obliterans?
*h/o smoking
* Onset of symptoms before the age of 50
* Infrapopliteal arterial occlusive disease
* Upper limb involvement
* Absence of risk factors for atherosclerosis outside of tobacco use.
Diagnosis is confirmed with a biopsy of vascular lesions.
s/s Thromboangiitis Obliterans (Buerger’s Disease) ?
forearm, calf, foot claudication
Ischemia of hands & feet
Ulceration and skin necrosis
Raynaud’s is commonly seen
What is the most effective treatment for Thromboangiitis Obliterans?
Smoking cessation is considered the most effective treatment for Thromboangiitis Obliterans.
treatment in Thromboangiitis Obliterans?
Smoking cessation-most effective tx
Surgical revascularization
No effective pharmacological tx
anesthesia implications for patients with Thromboangiitis Obliterans?
meticulous positioning and padding, avoidance of cold, warming the room, and using warming devices.
non-invasive blood pressure monitoring and conservative line placement are preferred.
What is Polyarteritis Nodosa?
Polyarteritis Nodosa is an antineutrophil cytoplasmic antibody (ANCA) negative vasculitis
may be associated with Hepatitis B, Hepatitis C, or Hairy Cell Leukemia.
Inflammation results in glomerulonephritis, myocardial ischemia, peripheral neuropathy and seizures
Renal failure is primary cause of death
What are the treatment options for Polyarteritis Nodosa?
Treatment options include steroids, cyclophosphamide, and treating the underlying cause, such as cancer.
What are the anesthesia implications for patients with Polyarteritis Nodosa?
coexisting renal disease, cardiac disease, and hypertension. Steroids are likely to be beneficial
What is Lower Extremity Chronic Venous Disease characterized by?
effects how much?
Lower Extremity Chronic Venous Disease is characterized by long-standing venous reflux and dilation.
effects 50% of population
mild - severe s/s of Lower Extremity Chronic Venous Disease?
telangiectasias, varicose veins (mild)
edema, skin changes, and ulceration (severe).
What are some risk factors for Lower Extremity Chronic Venous Disease?
Risk factors include
- Advanced age
- Family history
- Pregnancy
- Ligamentous laxity
- Previous venous thrombosis
- Lower extremity injuries
- Prolonged standing
- Obesity
- Smoking
- Sedentary lifestyle
- High estrogen levels
What are the diagnostic criteria for Lower Extremity Chronic Venous Insufficiency?
symptoms of leg pain, heaviness, and fatigue
Confirmed by ultrasound showing venous reflux
Retrograde blood flow > 0.5 seconds
What are the initial treatment options for Lower Extremity Chronic Venous Insufficiency?
Initial treatment typically involves conservative measures
Leg elevation
Exercise
Weight loss
Compression therapy
Skin barriers/emollients
Steroids
Wound management
What are some conservative medical management options for Lower Extremity Chronic Venous Disease?
diuretics, aspirin, antibiotics, prostacyclin analogues, and zinc sulfate.
*If management fails, ablation may be performed
What are the methods of ablation used for treating chronic venous disease?
- Thermal ablation with laser
- Radiofrequency ablation
- Endovenous laser ablation
- Sclerotherapy
What are the indications for ablation therapy in the treatment of chronic venous disease?
- Venous hemorrhage
- Thrombophlebitis
- Symptomatic venous reflux
What are the contraindications for ablation therapy in chronic venous disease?
- Pregnancy
- Thrombosis
- Peripheral Artery Disease (PAD)
- Limited mobility
- Congenital venous abnormalities
When is surgical intervention considered in the treatment of chronic venous disease?
Surgical intervention is usually considered as the last resort when other less invasive treatments have failed or are not suitable.
What are the types of surgical procedures available for chronic venous disease?
Saphenous vein inversion
High saphenous ligation
Ambulatory Phlebectomy
Transilluminated-powered phlebectomy
Venous ligation
Perforator ligation
Both ______ observed frequently during and after carotid endarterectomy
Both hypertension and hypotension may be observed frequently during andafter carotid endarterectomy
Acute arterial occlusion is typically caused by cardiogenic embolism. Emboli may arise _______
Other cardiac causes of systemic emboli are ________
Acute arterial occlusion is typically caused by cardiogenic embolism. Emboli may arise from a thrombus in the left ventricle that develops because of MI or dilated cardiomyopathy
Other cardiac causes of systemic emboli are valvular heart disease, prosthetic heart valves, infective endocarditis, left atrial myxoma, Afib, and atheroemboli
an inflammatory vasculitis leading to occlusion of small and medium-sized arteries and veins in the extremities
- Thromboangiitis obliterans
Pts at low risk for DVT require
minimal prophylactic measures such as early postop ambulation and compression stockings
The risk of DVT may be much higher in
patients >40 y/o
who are undergoing surgery >1 hour,
especially LE orthopedic, pelvic or abdominal surgery,
and surgeries that require a prolonged bed rest or limited mobility
