Vascular Complications Flashcards by Danielle Hoven

Carotid Artery Evaluation

-Carotid Bruit»Carotid US > CT angio of neck
<70%, asymptomatic = monitor and med manage
<70%, symptomatic = intervention
>70%, asymptomatic = intervention

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Carotid Interventions

–Medical management
BP control
Diet (low fat, low cholesterol, low sodium)
Antiplatelets (Plavix vs Aspirin)
Statin therapy
—Surgical
Open vs stent

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Carotid Artery Endarterectomy

-Asymptomatic (plaque >70%) or **symptomatic pts
-No previous h/o radiation therapy to neck
-No previous h/o of CEA to same side

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Open (endarterectomy (CEA))

-Removal of plaque
-Patch placed (bovine, Dacron)
-Post op Care:
Monitor incision (hematoma, bleeding)
Monitor BP (systolic 110-140)
Follow ECG and troponin (> risk of MI)
Neuro exam

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Nerves most affected after CEA

-Facial Nerve (CN VII) –perioral weakness, drool
-Glossopharyngeal (CN IX)- swallow
-Vagus (CN X)- vocal cord (hoarseness)
-Hypoglossal (CN XII)- tongue innervation

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Stenting (Carotid Artery Stent (CAS))

-Indications:
Plaque not approachable by CEA
High risk for cardiac complications
<70 yo
h/o radiation therapy on affected side
**symptomatic pts NOT candidate
-Puncture site at groin
-Post Op Care
Same as open procedure
> risk of stroke

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TCAR-Transcarotid Arterial Revascularization

-New hybrid procedure (carotid endarterectomy and stenting)
-Minimally invasive
-Small incision above collar bone and groin puncture site (venous)
-Temporary reversal of flow to prevent plaque embolization

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Arterial Structure

-Intima-inner most layer, thin wall
-Media-middle layer, thickest
-Adventitia-Outer layer

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Aneurysm Definition

Localized dilatation of an artery
Diameter >50% of normal diameter (varies-sex, age, bp)

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Ectasia Definition

Increase artery diameter but <50% of normal

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Dissection Definition

Abrupt tear along the inside of arterial wall

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Transection

Complete cut across artery or vein

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Abdominal Aortic Aneurysm Grading System

-Normal <2.5 cm
-Generous 2.5-3.0 cm
-Aneusym

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Abdominal Aortic Aneurysm Grading System

-Normal <2.5 cm
-Generous 2.5-3.0 cm
-Aneurysm: Small (3.0-3.5cm), Medium (3.5-4.5cm), Large (>4.5cm)

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Thoracic Aorta Locations

-Aortic arch
-Ascending
-Descending

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Abdominal Aorta Locations

-Infrarenal-Below the renal arteries
-Juxtarenal-infrarenal and involving one or both renal arteries
-Pararenal-involving one or both renal arteries
-Suprarenal-Above the renal arteries

Shapes of Aneurysm

-Fusiform
Symmetrical bulge around aorta
Most common
-Saccular
Asymmetrical & appears on one side of aorta
Likely r/t trauma or aortic ulcer
-Pseudoaneurysm
“False” aneurysm
Actual disruption of one or more of the wall layers

Medical Management of Aneursym

-Blood pressure control
-ASA
-Statin therapy
-Quite often missed treatment in pts with PAD/aneurysms
-Nicotine cessation
-Weight loss/increase activity tolerance

Possible Warrants of Medical Management: Aneurysms

-Aneurysms <5.4 cm, asymptomatic = every 6 months monitoring
-Aneurysms >5.4 cm, asymptomatic = may warrant repair
-Aneurysms <5.4 cm but symptomatic = warrant repair
-Symptoms can include: pulsatile abdominal pain, back pain,

Open Repair Surgical Intervention

-“Traditional” approach
-Longer length of hospital stay
-For those whose aortic anatomy not suitable for endovascular repair
No landing zone for stent graft
Tortuous aorta
-Definitive treatment
-Less frequent follow ups
-Risks: increased blood loss, MI, hemorrhage, injury to bowel or ureters, paraplegia, wound infection

Surgical Intervention: Endovascular

-Standard stent graft vs surgeon-modified vs manufactured fenestrated stent graft
Graft material polyester (Dacron) or polytetrafluoroethylene (PTFE)
-For those whose body habitus does not support an open repair
-Small percutaneous puncture/smaller femoral incision
—–Disadvantage
Frequent follow ups (every 3-4 months)
Potential for graft movement
Potential for endoleaks

Stenotic lower extremities

-Atherectomy (shaving of plaque)
-Stent
-Bypass (vein or prosthetic)

Compartment Syndrome

-Insufficient oxygen supply to muscles and nerves.
-Pain most common (motor and sensory loss=late signs)
-CK -follow serially q4-6hrs >1000 is concern
-Urine: Cr to assess renal function, Urine myoglobin (presence worrisome)
-Compartment Pressure ( >/= 30 mmHg + any of above highly suggestive)

Treatment of Compartment Syndrome

-Leg elevation
-IV Fluids (sodium bicarb)-prevent further renal failure and muscle breakdown)
-Fasciotomies

Peripheral Artery Disease

-Narrowed arteries reduce blood flow to arms and legs -Leg pain when walking (claudication) -Sign of buildup of fatty deposits (atherosclerosis) -Atherosclerosis causes narrowing of the arteries that can reduce blood flow (sometimes arms) -Complications include critical limb ischemia, stroke or MI

Symptoms of PAD

-Many people of mild to no symptoms -Claudication -Coldness in extremities -Leg numbness/weakness -Shiny skin on legs -Skin color changes -Slower growth of hair and toenails -Sores -Acutely pain may get works even at rest

Risk factors for PAD

-Smoking -HTN -HLD -Obesity -family hx -Age -High levels of amino acids called homocysteine

Prevention of PAD

-Nicotine cessation -Low fat diet -Control blood sugar -diet -BP and HLD management -Exercise

Ankle-Brachial Index (ABI)

-A way to dx PAD -Compres BP in the ankle and the BP in the arm -Also may get BPs taken before and after walking -Normal ABI is 1.10-1.40 -SBP in ankle/SBP in arm <0.9 is considered diagnostic of PAD <0.5 suggests severe PAD

Diagnosing PAD

-Blood test (lipids, CBC) -ABI -US of legs or feet -Angiography -Could be normal not to feel DP pulses bilaterally -Always should be able to feel a PT

Treatment for PAD

-Lifestyle modifications -Cholesterol meds -BP meds (BB) -Meds to control blood sugar -Antiplatelt/ Dual therapy -Meds for leg pain -Angioplasty and stent placement -Bypass surgery (uses healthy or synthetic vessel) -Thrombolytic therapy

Peripheral venous disease symptoms

-Swelling in legs, feet or ankles -Prescence of spider veins or varicose veins -Tired feeling in legs -Difficulty standing for long -Burning/numbness in thighs or calves -Itchy, dry skin -Same risk factors as PAD

Ateriovenous Fistula

-Pseudoaneurysm (irregular connection between artery and vein) -Purplish, bulging veins -Can cause blood clots to form -Internal bleeding risk -Swelling -Decreased BP -HF -Check with duplex US -CTA or MRA -Check for bruit -Treatment can be US guided compression -catheter embolization -Surgeyr

Varicose Veins

Twisted, enlarged veins -Most common in legs -Cause is weak vein walls and veins -PVD -Treatment could be sclerotherapy (injection of foam into veins) -Laser treatment -Catheter based procedures -High ligation and vein stripping -Ambulatory phlebectomy -Avoid long periods of sitting or standing -Raise legs -Avoiding tight clothing -Avoid salt and making lifestyle changes