Vascular Complications Flashcards
Carotid Artery Evaluation
-Carotid Bruit»Carotid US > CT angio of neck
<70%, asymptomatic = monitor and med manage
<70%, symptomatic = intervention
>70%, asymptomatic = intervention
Carotid Interventions
–Medical management
BP control
Diet (low fat, low cholesterol, low sodium)
Antiplatelets (Plavix vs Aspirin)
Statin therapy
—Surgical
Open vs stent
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
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
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
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
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
Arterial Structure
-Intima-inner most layer, thin wall
-Media-middle layer, thickest
-Adventitia-Outer layer
Aneurysm Definition
Localized dilatation of an artery
Diameter >50% of normal diameter (varies-sex, age, bp)
Ectasia Definition
Increase artery diameter but <50% of normal
Dissection Definition
Abrupt tear along the inside of arterial wall
Transection
Complete cut across artery or vein
Abdominal Aortic Aneurysm Grading System
-Normal <2.5 cm
-Generous 2.5-3.0 cm
-Aneusym
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)
Thoracic Aorta Locations
-Aortic arch
-Ascending
-Descending
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
