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Vascular Disease Flashcards

1
Q

What are some coexisting diseases that are commonly seen in vascular surgery patients? Which 3 are the MOST common?

A
  • CAD - 40-80% of vasc patient have this;
  • HTN- (most common);
  • Diabetes- (most common);
  • Smokers- (most common);
  • CNS; carotid disease stroke;
  • Renal
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2
Q

What percentage of vascular surg patients will have an MI postop that results in death?

A
  • 50% (not in the acute phase though)
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3
Q

If the surgical site has sclerosis what should we assume?

A
  • that other areas are sclerotic as well
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4
Q

What are the risk factors for vascular disease?

A
  • Diabetes mellitus;
  • Dyslipidemia;
  • Family history;
  • Hypertension;
  • Obesity;
  • Older age: 75 y/o and up;
  • Smoking (2x)
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5
Q

What is the most common occlusive disease in the lower extremity arteries?

A
  • Atherosclerosis
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6
Q

What are three pathophysiologic processes that affect arteries?

A
  • Plaque formation;
  • Thrombosis;
  • Aneurysm formation
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7
Q

What are 4 S/Sxassociated with peripheral occlusive disease?

A
  • Claudication;
  • skin ulcerations;
  • gangrene;
  • impotence
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8
Q

What are two common causes of vascular aneurism?

A
  • HTN;
  • Vascular damage
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9
Q

If a patient is on ED drugs what should we assume?

A
  • That vascular disease is everywhere in the body → thats why they have impotence
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10
Q

What is the treatment for peripheral occlusive disease?

A
  • Pharmacologic therapy OR;
  • Transluminal angioplasty;
  • Endarterectomy;
  • Thrombectomies;
  • Multiple bypass procedures
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11
Q

In a patient with vascular disease what other issues should we be sure to evaluate in preop? Why does it matter?

A
  • CAD;
  • pulm dysfunction;
  • renal dysfunction;
  • neuro dysfunction;
  • endocrine dysfunction;
  • Matters d/t disease process not being limited to arterial beds in periphery → its everywhere
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12
Q

What is the primary goal for invasive monitoring of a vascular surg patient?

A
  • detection of cardiac ischemia → a-line may be important for these patients
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13
Q

What monitoring should we consider for a vascular surg patient?

A
  • Depending on patient:;
  • a-line PA cath and TEE are all warranted for assessing CV function
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14
Q

How should we approach anesthetic selection for a vascular disease patient?

A
  • Depends on surg type but consider:;
  • LA and IV concious sedation;
  • Regional anesthesia;
  • General anesthesia
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15
Q

Why are spinals and epidurals contraversial for peripheral vascular surgery?

A
  • patient is being anticoagulated
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16
Q

What are two important issues after peripheral vascular surgery?

A
  • Pain management;
  • Monitoring
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17
Q

When doing bypass grafting on upper/lower extremities for occlusive disease or aneurysms what are some viable anesthesia options?

A
  • General;
  • Regional
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18
Q

What can cause intermittent claudication?

A
  • When demand exceeds supply
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19
Q

What is “Rest Pain”?

A
  • Rest pain is a constant burning pain from wounds that won’t heal.;
  • Associated with peripheral vascular disease
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20
Q

What can improve “Rest Pain”?

A
  • ↑ hydrostatic pressure → albumin can help with this
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21
Q

What are some S/Sx of intermittent claudication?

A
  • ↓ or absent pulses;
  • Bruits in abdoment pelvis inguinal area (remember clots often happen at bifurcations)
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22
Q

If a patient presents with hair loss on their lower extremities what should you think of?

A
  • Peripheral vascular disease causes subq atrophy and hair loss
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23
Q

What are the three classifications of the Ankle-brachial index?

A
  • If ABI is:;
  • < 0.9 claudication;
  • < 0.4 rest pain;
  • < 0.25 impending gangrene
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24
Q

What is the ankle-brachial index (ABI)? How do we calculate it?

A
  • the ratio of the BP at ankle to BP in upper arm;
  • Ankle SBP / Arm SBP
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25
Q

If the BP in the leg is lower than BP in the arm what does that tell us?

A
  • ↓ leg BP indicates blocked arteries d/t PAD
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26
Q

What are some treatment options for PVD?

A
  • Exercise;
  • Stop smoking;
  • Treat HTN CAD DM;
  • β-antagonists MAYBE → If someone has demand ischemia Beta blockers can reduce peripheral perfusion;
  • ↓ lipids;
  • Revascularization vs amputation
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27
Q

When might revascularization for PVD be considered?

A
  • Disabling claudication;
  • Ischemic rest pain;
  • Impending limb loss
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28
Q

What are the main components of the revascularization procedure?

A
  • Angioplasty;
  • May stent may not;
  • Iliac and femoral/popliteal arteries common
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29
Q

What are some anesthesia concerns with revascularization cases?

A
  • patients prob too sick to do surgical CAD → need pharmacological stress test;
  • is patient on β blockers preop?;
  • Vessels often harvested from other areas of body so regional might be tricky;
  • Patient will be anticoagulated → more bleeding
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30
Q

What is the 3rd leading cause of death in the U.S.?

A
  • Stroke
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31
Q

What two types of stroke are there and which is the most common?

A
  • Hemorrhagic and Ischemic;
  • 87% are ischemic
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32
Q

What is the difference between a TIA and a Stroke?

A
  • TIA always caused by temporary ischemia never bleeding. Stroke can be bleeding or ischemia
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33
Q

What does a TIA suggest?

A
  • impending stroke
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34
Q

How strong is the correlation between TIA and impending stroke?

A
  • 10x more likely than age/sex matched
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35
Q

What are risk factors for stroke?

A
  • Age;
  • Atrial fibrillation;
  • Black race;
  • History/family history;
  • HTN/smoking/diabetes;
  • Hypercholesterolemia;
  • Male;
  • Obesity;
  • Sickle cell disease
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36
Q

In the brain which vessel is the most common place for a clot to occur?

A
  • Internal carotid
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37
Q

What are some ways we might diagnose a stroke?

A
  • Angiography;
  • Carotid bruit;
  • Carotid stenosis;
  • Sudden neurological deficits
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38
Q

Where does carotid stenosis most often occur?

A
  • Carotid bifurcation → most common place for atherosclerotic plaque buildup
39
Q

How do we treatment an acute ischemic stroke?

A
  • TPA within 3-5 hrs (NNT=10 →https://www.thennt.com/thennt-explained/);
  • Intra-arterial thrombolysis
40
Q

How can we treat/prevent ischemic strokes in the long term?

A
  • Stop smoking;
  • Antiplatelet therapy;
  • Correct or ↓ hypoxia hypertension unstable arrhythmias;
  • Carotid endarterectomy
41
Q

Why are cardiac arrythmias common in stroke? What can reduce this risk?

A
  • when the docs start working on the clot pieces break off and travel…;
  • Translumenal procedures ↓ this risk
42
Q

What are some anesthesia concerns for patients receiving intra-arterial thrombolysis?

A
  • Commorbidities → major cause of mortality postop;
  • Good BP control → want good cerebral autoregulation;
  • Consider effects of their head being rotated WRT blood flow;
  • Consider regional so we can keep them awake to monitor for stroke
43
Q

What area of the aort is the most difficult to treat? Which area is easier?

A
  • Ascending more difficult;
  • Abdominal less difficult
44
Q

What are two types of vessel abnormalities we might see on the aorta?

A
  • Aneurysm →Dilation with 50% increase in diameter;
  • Dissection →Blood enters media layer from tear in intima
45
Q

What are two major complications for anesthesia during aorta repair surgery?

A
  • Need to cross-clamp the aorta;
  • Potential for large intraoperative blood loss
46
Q

Related to aortic cross clamping what are some cardiac specific changes that occur?

A
  • Acute ↑↑↑ LV afterload and severe HTN;
  • Myocardial ischemia;
  • LV failure;
  • Aortic valve regurg
47
Q

Related to aortic cross clamping what are some critical perfusion specific changes that occur?

A
  • Compromises organ perfusion distal to point of occlusion;
  • Interrupts BF to spinal cord and kidneys → results in paraplegia and renal failure
48
Q

What can happen after the aortic clamp is released and why? How do we prevent this?

A
  • Patient might become hypotensive d/t blood loss and not having enough volume to fill system when clamp is released;
  • Volume loading can help
49
Q

What are 5 indications we discussed in class for aortic surgery?

A
  • Aneurysms;
  • Aortic dissection;
  • Coarctation;
  • Occlusive disease;
  • Trauma
50
Q

What are the two types of coarctation of the aorta? How are they classified?

A
  • pre-ductal (infant);
  • post ductal (might not know until adult);
  • Classified according to relative position WRT ductus arteriosis
51
Q

Related to aortic surgery what are the 4 site specific lesions we need to know?

A
  • Aortic arch;
  • Ascending aorta;
  • Below the diaphragm;
  • Distal to left subclavian artery and above diaphragm
52
Q

Related to aortic surgery how will we know if cardiopulmonary bypass is required?

A
  • Lesions involving the ascending and transverse aorta require bypass
53
Q

How are aortic dissections classified?

A
  • DeBakey I II III;
  • –OR–;
  • Stanford A (proximal) or B (Distal)
54
Q

Describe each of the DeBakey classifications?

A
  • DeBakey I → Dissection in the ascending aorta that extends into the descending aorta;
  • DeBakey II → Dissection in the ascending aorta that does notextend into the descending aorta;
  • Debakey III → Dissection in the descending aorta distal to left subclavian;
  • Debakey IIIA → extension to abdominal aorta;
  • Debakey IIIB → doesn’t extend to abdominal aorta
55
Q

What is an aortic dissection?

A
  • Characterized by a spontaneous tear of the vessel wall intima permitting the passage of blood along false lumen
56
Q

What is the most common factor contributing to the progression of an aortic dissection? Most serious complication is?

A
  • Common factor = HTN;
  • Complication = aneurysm rupture
57
Q

Stanford classification Type A converts to DeBakey how?

A
  • Stanford Type A = DeBakey I and II
58
Q

How are dissecting aortic lesions treated?

A
  • Proximal dissections nearly always treated surgically;
  • Distal dissections may be managed medically initially;
  • Measures to reduce SBP and wall stress are initiated once diagnosis confirmed
59
Q

Which dissecting aortic lesions have the highest incidence of rupture?

A
  • Proximal lesions
60
Q

What is a “True” aneurysm? What is a “False” aneurysm?

A
  • True → Involves dilation of all 3 layers of the vessel wall;
  • False → Caused by disruption of 1 or more layers of the vessel wall
61
Q

What are the 3 layers of a vessel wall?

A
  • Tunica externa (outer);
  • Tunica Media (middle);
  • Tunica interna (inner)
62
Q

What is the most common location for aortic aneurysms? What is the most common cause?

A
  • abdominal aorta;
  • atheroslcerosis or medial cystic necrosis ← he mentions both on slide 36 as being the common cause
63
Q

What are some important complications of AAA to know?

A
  • Depending on site:;
  • aortic regurg;
  • tracheal or bronchial compression or deviation;
  • hemoptysis;
  • superior vena cava syndrome
64
Q

Which part of the aorta do syphalitic aneurysm generally involve?

A
  • ascending aorta
65
Q

What is the greatest danger of aortic aneurysm?

A
  • rupture and exsanguination
66
Q

What is the normal size of the aorta in adults? When would an aortic resection be performed?

A
  • normal = 2-3 cm in width;
  • Electrive resection typ done when aneurysm is > 4 cm (later he says ≥ 5-6 cm??)
67
Q

When does a pseudoaneurysm form?

A
  • when the intima and media are ruptured andonly the adventitia or blood clotform the out layer of the vessel
68
Q

Thromboembolic occlusion of the aorta is most commonly due to what?

A
  • atherosclerosis;
  • Combo of atheroslerotic plaque and thrombosis
69
Q

How do we treat thromboembolic occlusion of the aorta?

A
  • Aorto-bifemoral bypass;
  • Possible proximal thromboendarterectomy
70
Q

What are the two types of aortic trauma? What diagnostic shows you that bleeding is occurring?

A
  • Penetrating or non-penetrating injury;
  • CXR with wide mediastinum indicates bleeding
71
Q

Why is it important to do a GOOD preop on vascular surgery patients?

A
  • Patient frequently elderly and lots of concurrent diseases;
  • Special attention given to cardiac renal and neuro function;
  • Preop renal dysfunction directly r/t postop renal failure
72
Q

Where is the most common location for a thoracic aneurysm to develop?

A
  • Just above aortic valve distal to left subclavian takeoff → Ligamentum arteriosum
73
Q

What are risk factors for thoracic aneurysm?

A
  • Age;
  • Aortic cannulation;
  • Atherosclerosis;
  • Blunt trauma;
  • Crack cocaine;
  • Hypertension;
  • Male sex;
  • Marfan’s syndrome;
  • Smoking
74
Q

Why is Marfans syndrome prone to causing aneurysms?

A
  • Vasculature can’t keep up with the increased size of patients with the syndrome
75
Q

What are the two classes of aneurysms?

A
  • Saccular → eccentric dilation;
  • Fusiform → entire circumference of aorta
76
Q

Which class of aneurysm often occurs at the renal arteries?

A
  • Fusiform
77
Q

What are some S/Sx of a thoracic aneurysm?

A
  • Often asymptomatic and but exam can find:;
  • Hoarseness;
  • Stridor;
  • Dyspnea;
  • Dysphagia;
  • Dilation of aortic valve annulus
78
Q

What are some S/Sx of acute aortic dissection?

A
  • Severe sharp tearing pain;
  • Hypotension/hypertension;
  • Absence of peripheral pulses;
  • Paraplegia/paraparesis
79
Q

How do we diagnose aneurysms/aortic dissections?

A
  • CXR;
  • TEE;
  • Arteriogram
80
Q

How are aortic dissections treated?

A
  • Stent;
  • Open surgery
81
Q

What is “anterior spinal artery syndrome”? What are some adverse S/E?

A
  • major complication of cross clamping of thoracic aorta with > 30 min cross clamp times;
  • Flaccid paralysis loss of bowel/bladder renal insufficiency;
  • Loss of motor function and pinprick sensation but preservation of vibration and proprioception
82
Q

What famous artery perfuses the anterior spinal artery?

A
  • Artery of Adamkiewicz or the greater radiculmedullary artery
83
Q

If you notice a patient has a pulsatile abdominal mass on exam what would you suspect?

A
  • Abdominal aneurysm → common in people > 60 y/o
84
Q

How might we diagnose an abdominal aneurysm?

A
  • Abdominal ultrasound;
  • Helical CT - to see if endovascular repair is feasible;
  • MRI
85
Q

What is the treatment regime for abdominal aneurysms?

A
  • <4cm → US q6 mo;
  • 4-5cm → elective repair w/low operative risk and good life expectancy.;
  • 5-6 cm → need repair (mortality rate 0.9-5%);
  • 6-7 cm → threshold for rupture (mortality as high as 75%).
86
Q

What are the classic S/Sx of an abdominal aneurysm rupture? What percentage of patients do these S/Sx appear?

A
  • Hypotension;
  • Back pain;
  • Pulsatile mass;
  • S/Sx only present in 50% of patients (hemorrhage and tamponade into retroperitoneum also happens)
87
Q

If we are doing a case where surgery is performed on the ascending aorta which arm are we going to place our art line in? What med will we used to contro BP and why?

A
  • Left radial is used d/t cross clamping of the aorta;
  • Will use nitroprusside instead of nicardipine d/t needing fast on/fast off
88
Q

Surgery on the aortic arch and ascending aorta use what approach?

A
  • Aortic arch → median sternotomy with deep hypothermic circulatory arrest;
  • Ascending aortia → cardiopulm bypass
89
Q

For surgery involving the aortic arch what are import considerations needed to provide the best cerebral protection?

A
  • Know that long rewarming periods contribute to intraoperative blood loss;
  • Mannitol;
  • Methylprednisolone or dexamethasone;
  • Narcotic infusion;
  • Phenytoin;
  • Systemic and topical hypothermia (15° C)
90
Q

What is the most common location that the Artery of Adamkiewicz arises?

A
  • T9-T12 (60% of people) → almost always on the left side
91
Q

How do we calculate spinal cord perfusion pressure?

A
  • Spinal Perf Pressure = MAP - SCP
92
Q

How might we monitor for paraplegia when doing a case with aortic cross clamping?

A
  • SSEP
93
Q

What are some protective therapeutic measures we can take before the surgeon cross clamps the aorta?

A
  • Methylprednisolone;
  • Mild hypothermia;
  • Mannitol (0.5g/kg);
  • Renal dose dopamine (1-3 mcg/kg/min);
  • Fenoldopam (0.05-0.1 mcg/kg/min);
  • Maintain BP;
  • Drainage of CSF
94
Q

What is ↑ renal failure following aortic surger a result of?

A
  • Emergency procedures;
  • Prolonged cross-clamp periods;
  • Prolonged hypotension

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