vascular Flashcards
early defection post op
-tachy, hypotension
-IMA!!! (not SMA) loses perfusion -> left colon dies -> ischemia
-not enough colaterization of SMA to IMA via marginal artery
-sloughing off of the bowel- mass contraction
-STAT sigmoid scope to look for how much ischemia
-EMERGENT surgery before colon perforates
-hartmanns or reimplant IMA if you can
-LLQ pain, fever, diarrhea, bloody stool
lower extremity vasculature
-at the inguinal ligament the external iliac becomes the common femoral artery
-superior, middle, inferior genicular arteries - collateral circulation
-anterior tibial -> dorsalis pedis
first and last branch off the abdominal aorta
-last- median sacral artery
-first branch off is the inferior phrenic
ischemia of lower limb risk factors
-Advanced age
-Race (non-Hispanic blacks).
-Male gender.
-Diabetes
-Dyslipidemia.
-Smoking.
-Hypertension.
-Hypercoaguability.
-Chronic kidney disease.
signs of ischemia of the lower limb
-Vascular Claudication- distance you can walk is uniform -> rest -> repeat
vs
-Neurogenic Claudication- lumbar nerves -> non-uniform, varies with distance, feet are warm
-Acute signs:
-6 P’s
-Pallor
-Pain
-Paresthesia
-Paralysis
-Pulselessness
-Poikilothermia- cold
history
-Hx of vascular disease and their interventions
-Cardiac hx and search for current symptomatology.
-Smoking history.
-Food aversion.
-Visual events.
-H/O diabetes.
-Claudication.
-Rest pain.
-Nonhealing ulcers- medial (venous) vs lateral (arterial)
-THEY ARE VASCULOPATHS!
plaque
physical exam
-Blood pressure in both upper extremities.
-Peripheral pulse assessment (presence, strength, and character). This is NOT just feeling pulses it is interpreting them.
-Lower extremity motor and sensory examination.
-Muscle wasting, thin and dry skin, or ulceration may be present.
-Hypertrophic nails, hair loss, loss of subcutaneous tissue, cold or cool extremity, arterial ulcers -> mottled
pulses to check
-Radial
-Ulnar
-Brachial
-Carotid
-Femoral
-Popliteal
-Dorsalis Pedis
-Posterior Tibialis
-Listen for Bruits as well
-Perform ABI
ankle brachial index (ABI)
-ABI of >1.2: Calcification of arteries
-3-4: calcified artery- DM2 -> Mönckeberg’s sclerosis (MS)
-ABI of 0.9 – 1.2: Normal.
-ABI of <0.9: Suggests arterial stenosis
work up
arterial dopplers- turbulent flow
-pulse volume recordings
-CTA
-high velocity flow - stenosis
-BART- blue away, red towards
pulse volume recordings
-cuff that has lower wave -> disease is proximal
-dimished tracing - disease is proximal
-disease starts in right iliac -> gets worse as you move down
-plaques
-poor circulation on the right
-reconstitute-
-claudication- walk through the pain -> anoxia is a stimulate for vascular growth -> collateral circulation
-walking program
-left - reconstitution of flow -> flow below the knee
-distal SFA proximal popliteal
-level of the ADDUCTOR CANAL that you find the MC area for occlusion of the superficial femoral artery !!!!!!!!!!!!!!!! bc of intrinsic compression
-reconstitutes distally bc of flow through geniculate arteries -> collateral
-older pts do better - hypertrophic nails, hair loss -> signs that there is collateral circulation
-younger (afib) -> no collaterals -> limb loss
acute limb ischemia: most important preoperative assessment
-40 - 50% of pts with PAD have CAD
-GOAL: Improvement of cardiovascular function and stabilization of cardiac issues through optimization is the prime directive.
-Beta-blockers**
-Anti platelet agents- maybe not post op -> bleeding risk
-Statins**
-ACE inhibitors
-BB and statins- continue post op if they were taking it before
-if you stop statins abruptly -> plaque instability -> occlusions
treating vascular pt: conservative approach
-Smoking cessation
-Exercise program- claudication -> anoxia -> collaterals
-Statins/diet modification
-Anti-platelet therapy
vascular surgical approach
-acute limb ischemia- HEPARIN
-critical ischemia
-heparin
-thrombectomy
-embolectomy
-thrombolysis
-fasciotomy- ischemic -> after 3 hrs -> irreversible muscle damage -> swelling -> cuts off circulation in leg -> limb loss
what is approach to PAD once conservative measures fail
-Endovascular interventions:
-Angioplasty (percutaneous)
-Stents
-Bypass- last choice
-balloon- crack the plaque
PAD lesions
-femoropopliteal - PTFE (a tube) is okay
-infrapopliteal- vein
-KEY ASPECT- above and below the knee
-once you get bending of the knee polytetrafluoroethylene (PTFE) grafts dont do well -> occlude
-below knee -> use vein (saphenous, umbilical, composit) -> something more sturdy
femoropopliteal lesions (dont need to know)
-as letter go up -> worse
-Type A: focal lesion less than 3 cm in length and do not involve the origins of the SFA or the distal popliteal artery.
-Type B: single lesions 3 to 5 cm in length not involving the distal popliteal artery or multiple or heavily calcified lesions less than 3 cm in length.
-Type C: lesions, multiple stenoses or occlusions greater than 15 cm in length or recurrent stenoses or occlusions that need treatment after two endovascular interventions.
-Type D: lesions are those with complete occlusion of CFA, SFA, or popliteal artery
PAD events
-acute limb ischemia-anticoagulation- heparin w/o bolus
-embolic event-balloon embolectomy- if embolism -> stick catheter in -> balloon -> pull clot out
-send to pathology after
-arterial thrombosis -catheter -> thrombolytic agents -> IR TPA directly to the area
-stent
complications
-Muscle injury
-Compartment Syndrome- fasciotomy -> wound grafts may be needed
-Rhabdomyolysis- IV fluids, check CPK
-Limb Loss
chronic limb ischemia finding
->2 weeks duration
-ulcers
-ischemia rest pain
-abnormal ABI
venous vs arterial ulcers
VENOUS
-Location:Medial part of lower legs, around medial malleolus.
-Appearance:Shallow, irregular borders, indurated and dark skin around ulcer.
-Discomfort:Low level of discomfort, not painful unless infected.
-Other Symptoms:Leg swelling
-gaiters area- venous disease -> tibial tuberosity and down
ARTERIAL
-Location:Feet, heels, toes of legs (Lateral).
-Presentation:Round shape, regular margins, pale/yellow base, feel stiff with cold skin.
-Pain –Can be painful mostly when walking.
-Other symptoms:Affected leg or foot cool to the touch, shiny skin, loss of hair, muscle atrophy.
fem-pop disease
-non limb threatening
-claudication
-limb threatening (revascularization):
-rest pain
-ulcerations
-gangrene - dry or wet - IV/local antibx, debridement, wound care
-mal perforans- arterial ulcer
-hammer toes
-DM
indications for surgery for chronic disease
-Claudication limiting lifestyle - if you can still walk 3 blocks -> surgery is too risky
-Ischemic rest pain.
-Tissue loss.
-Gangrene wet or dry.
-type a- endovascular
-B&C- no recommendation
-D- open procedural interventions
-antegrade
-retrograde
-scaffolding- antiproliferative compounds- block proliferation of plaques
-adventitial- dexamethasone- prevent proliferation of plaque
percutaneous graft
-PTFE is used bc its above the knee
-tube
-saphenous or umbilical vein
-fem-pop
-fem-tibial
-profundaplasty
-must assess distal vessels
-want 2 out of 4 distal vessels patent
-you need to ensure inflow and OUTFLOW
-without outflow -> it wont work
aorta occlusion tx
-open aorta for tx?
-axillobifemoral bypass
-tight clothes, belt, sleeping on it -> issues
-tube grafts made of PTFE- pseudointima forms -> transient bacteremia
-prophylactic antibiotics
-stent
AAA tx
-left renal vein - comes off the IVC - just superior to the neck of the aneurysm
-most aneurysms are infrarenal
-move left renal vein superior
-transect and cut left renal if its over the aneurysm
-open aorta- understand that there will be plaque and the IMA is already occluded
-tube or Y graft- both left and right iliacs
-vasa vasorum goes all around the aorta to bring O2
-adventitia and outer part wont get O2 -> cant produce elastic or collagen
-weakens
-inside filled with plaque -> O2 cant get through -> intima weakens
-harden and balloon out
-sheer flow -> causes plaques
-laminated clot- thrombus
-measure it
-from outer wall to outer wall
-medially
-lateral view of abdomen
-pick up calcifications of aorta
-allow you to see
-not used anymore
-saccular aneurysm
-longitudinal view
-aneurysm
-impended rupture
-mass felt
-CTA allow you to plan the surgery
-look at other vasculature
-kidneys- horseshoe kidneys
-ruptured but contained aneurysms
-blood retroperitoneal
-plan surgery
-not ideal
-tube (2 anastomose) or wire (1 proximal and 2 distal- left and right iliac) graft
surgical options AAA
-Endovascular Repair (EVAR)- ideal
-measurements
-find out which graft you need
-tube or wire (shown in pic)
-stents
-aneurysm is still there but you made a new lumen
-Open Repair- brutal
-cross clamp the aorta to stop bleeding
-cross clamp each iliac artery and aorta below the renal arteries
-posterior lumbars will still bleed
-2-3L of blood is lost usually
-autotransfused back to the pt
-graft in an open repair
-aorta closed over the graft
-dont want the graft to touch the bowel -> infection
-aorta fistulas can form
carotid disease symptoms
-numbness or tingling on the face, arm, leg
-confused dizzy
-trouble seeing
-headaches
-difficulty walking/balance
-difficulty swallowing
-usually one side of body
-TIA
-subclavian steal- reversal of flow -> prevertebral subclavian artery stenosis
indications for carotid artery surgery
-North American Symptomatic Carotid Endarterectomy Trials (NASCET)1987.
-Pts with 50% or more stenosis.
-H/O ipsilateral stroke or TIA.
-Asymptomatic patients with 70% or more narrowing
-Carotid endarterectomy- check backflow from other carotid first
-open- take out plaque- stent and shunt first so blood can still flow
-stent
-fibromuscular dysplasia- curly findings
-normal
-MRI
-plaque
-MRI
-carotid siphon
-large vessel disease in their brain
-may need internal to external carotid bypass
-done by neurosurgeon
-bruits if enough stenosis
-plaque forms at areas of bifurcations bc of turbulent flow
-narrows lumen of vessel
-pressure gradient
TCAR
-allows you to use a system put into a filter and is returned to the pt
-negative flow -> reversal flow
-any debree cant go to brain -> sucked back and returned to extremity while taking out the plaque
-allow you to perform surgery
-embolic filter that doesnt get debris back into
open carotid endarectomy
-patch angioplasty
-remove plaque in its entirety
-open procedure
-gortex or saphenous vein
-necessary so you dont cause a point of stenosis
hypercoagulable states
common findings in mesenteric ischemia
-THUMBPRINTING
-Left is normal
-right is occluded at the SMA
-US
-picture on the right is ischemia for the entire bowel -> bad
-CTA
-pneumatosis intestinalis
-surgery
-lactic acidosis - ischemia
-put pt on heparin if there is suspicious areas of ischemia -> look again -> try to salvage what you can
-short gut syndrome- total parental nutrition for life
