Vascular Flashcards
Where are clots usually formed?
bifurcations / turbulent flow areas
Vascular Surgery Patients Coexisting diseases:
CAD 40-80%
HTN
Diabetes
Smokers
CNS; carotid disease, stroke
Renal
vasopressors- high dose
50% of Vascular Surgery Patients post op mortalities d/t
MI
Risk Factors for vasular dx
Older age: 75 y/o and >
Family history
Smoking (2x)
Diabetes mellitus
Hypertension
Obesity
Dyslipidemia
most common cause of occlusive disease in the arteries of lower extremities
Atherosclerosis
Symptoms associated with peripheral occlusive disease
Claudication, skin ulcerations, gangrene, and impotence
Extent of disability is influenced with development of ……
collateral blood flow
Treatment for peripheral occlusive disease:
Pharmacolgic therapy
Surgical therapy:
Transluminal angioplasty
Endarterectomy
Thrombectomies
Multiple bypass procedures
Postoperative considerations for PERIPHERAL VASCULAR DISEASE
Administration of narcotics
Epidural opioids and local anesthetics
Postoperative monitoring
Diagnosis of PVD;
Intermittent claudication
Rest at pain
Decreased/absent pulses
Bruits in the abdomen, pelvis, and inguinal area
Subq atrophy, hair loss
ultrasound no flow
Ankle-brachial index and associated levels
bp in ankle and brachial (non invasice)
< 0.9 claudication
< 0.4 rest pain
< 0.25 impending gangrene
Treatment for pvd
Exercise programs
Stop smoking
Treat HTN, CAD, DM
Lipid lowering
Revascularization vs amputation
Common places for revasularization
Iliac vs femoral/popliteal
advantages or regional over general
Increased blood flow
Anticoagulation
Dementia
Spine surgery
Upper extremity harvesting
Carotid Artery Disease rate of death and types
Stroke 3rd leading cause of death
Hemorrhagic
Ischemic
87% are ischemic
Most common carotid occlusion site
internal cartoid artery
thecarotidbifurcation, where thecommon carotiddivides into the internal and externalcarotid
Risk Factors for Carotid artery disease
Age
History/family history
Black race
Male
Sickle cell disease
HTN/smoking/diabetes
Atrial fibrillation
Hypercholesterolemia
Obesity
Procedure on aorta are complicated by
Need to cross-clamp the aorta
Potential for large intraoperative blood loss
Aortic cross-clamping
Acutely increases LV afterload; severe HTN, myocardial ischemia, LV failure, or aortic valve regurgitation
Comprises organ perfusion distal to point of occlusion; interruption of blood flow to the spinal cord and kidneys can produce paraplegia and renal failure
hardest aneurysm to treat
ascending
Indications for aortic surgery include
Aortic dissection
Aneurysms
Occlusive disease
Trauma
Coarctation
most common factor contributing to the progression of the lesion/ aneurysm
htn
AORTIC DISSECTION is what?
Characterized by a spontaneous tear of the vessel wall intima, permitting the passage of blood along a false lumen
Treatment of dissecting aortic lesions:
Proximal dissections are nearly always treated surgically
Distal dissections may be managed medically initially
Most common cause of abdominal aortic aneurysm
medial cystic necrosis
can also have RA, athero, spondyloarthropathies, and trauma
What aneurysms require cardiopulmonary bypass
Ascending and transverse
Vessel walls
tunica externa- fibrous connective tissue
tunica media- smooth muscle/elastic tissue
tunica interna - epithelial layer, squamous cells
Classic symptoms for aortic rupture
Hypotension
Back pain
Pulsatile mass
Only present 50% experience hemorrhage and tamponade into retroperitoneum
Most common site for thoracic aneurysm
Just above aortic valve
Just distal to left subclavian takeoff
Ligamentum arteriosum
Classic deficit is that of an anterior spinal artery syndrome:
Loss of motor function and pinprick sensation but preservation of vibration and proprioception
Artery of Adamkiewicz arises
Arises from
T5-T8 in 15% of the pop.
T9-12 in 60%. - most common
L1-L2 in 25%.
Nearly always arises on the left side.
Increased incidence of renal failure following aortic surgery associated with:
Emergency procedures
Prolonged cross-clamp periods
Prolonged hypotension
Spinal cord perfusion pressure
Spinal cord perfusion pressure = MAP- SCP
Dx for carotid artery dz
Carotid bruit
Carotid stenosis
Sudden neurological deficits
Angiography
What is considered and aneurysm
Dilation with 50% increase in diameter
What is a dissection
Blood enters media layer from tear in intima
Debakey 1 and Debakey 2
Both are Standford A (proximal)
Debakey 3
Standford B (distal)
dividing line for Stanford A and B
Innominate artery
normal aorta width
2-3 cm
elctive resections generally with aneurysms greater than 4 cm
things Found on exam
Related to compression of adjacent structure
Hoarseness
Stridor
Dyspnea
Dysphagia
Dilation of aortic valve annulus
DX for thoracic aneurysm
CXR
TEE
Arteriogram
tx for thoracic aneurysm
Elective procedure >/= 5-6 cm
Which aneurysm has a genetic link
abdominal aneuysms
Abd aneurysm diagnosis
Abdominal ultrasound
Helical CT; 3D for endovascular feasibility
MRI; Lack of radiation/contrast medium
threshold for rupture (mortality as high as 75%- abd aneurysm
6-7 cm
abd aneurysm need repair at what size
5-6 cm
size of abd aneurysm for elective repair w/low operative risk and good life expectancy.
4-5cm
Characteristics of anterior spinal artery syndrome
loss of bowel and bladder function
Activation of which reflex may cause bradycardia in carotid surgery
baroreceptor
Which anesthesia technique is preferred for carotid surgery
regional
The risk of pneumonia is how many times higher in smokers than non smokers
twice as high
