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
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)
3
Q
If the surgical site has sclerosis what should we assume?
A
- that other areas are sclerotic as well
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)
5
Q
What is the most common occlusive disease in the lower extremity arteries?
A
- Atherosclerosis
6
Q
What are three pathophysiologic processes that affect arteries?
A
- Plaque formation;
- Thrombosis;
- Aneurysm formation
7
Q
What are 4 S/Sxassociated with peripheral occlusive disease?
A
- Claudication;
- skin ulcerations;
- gangrene;
- impotence
8
Q
What are two common causes of vascular aneurism?
A
- HTN;
- Vascular damage
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
10
Q
What is the treatment for peripheral occlusive disease?
A
- Pharmacologic therapy OR;
- Transluminal angioplasty;
- Endarterectomy;
- Thrombectomies;
- Multiple bypass procedures
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
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
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
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
15
Q
Why are spinals and epidurals contraversial for peripheral vascular surgery?
A
- patient is being anticoagulated
16
Q
What are two important issues after peripheral vascular surgery?
A
- Pain management;
- Monitoring
17
Q
When doing bypass grafting on upper/lower extremities for occlusive disease or aneurysms what are some viable anesthesia options?
A
- General;
- Regional
18
Q
What can cause intermittent claudication?
A
- When demand exceeds supply
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
20
Q
What can improve “Rest Pain”?
A
- ↑ hydrostatic pressure → albumin can help with this
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)
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
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
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
25
If the BP in the leg is lower than BP in the arm what does that tell us?
* ↓ leg BP indicates blocked arteries d/t PAD
26
What are some treatment options for PVD?
* 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
27
When might revascularization for PVD be considered?
* Disabling claudication;
* Ischemic rest pain;
* Impending limb loss
28
What are the main components of the revascularization procedure?
* Angioplasty;
* May stent may not;
* Iliac and femoral/popliteal arteries common
29
What are some anesthesia concerns with revascularization cases?
* 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
30
What is the 3rd leading cause of death in the U.S.?
* Stroke
31
What two types of stroke are there and which is the most common?
* Hemorrhagic and Ischemic;
* 87% are ischemic
32
What is the difference between a TIA and a Stroke?
* TIA always caused by temporary ischemia never bleeding. Stroke can be bleeding or ischemia
33
What does a TIA suggest?
* impending stroke
34
How strong is the correlation between TIA and impending stroke?
* 10x more likely than age/sex matched
35
What are risk factors for stroke?
* Age;
* Atrial fibrillation;
* Black race;
* History/family history;
* HTN/smoking/diabetes;
* Hypercholesterolemia;
* Male;
* Obesity;
* Sickle cell disease
36
In the brain which vessel is the most common place for a clot to occur?
* Internal carotid
37
What are some ways we might diagnose a stroke?
* Angiography;
* Carotid bruit;
* Carotid stenosis;
* Sudden neurological deficits
38
Where does carotid stenosis most often occur?
* Carotid bifurcation → most common place for atherosclerotic plaque buildup
39
How do we treatment an acute ischemic stroke?
* TPA within 3-5 hrs (NNT=10 → https://www.thennt.com/thennt-explained/);
* Intra-arterial thrombolysis
40
How can we treat/prevent ischemic strokes in the long term?
* Stop smoking;
* Antiplatelet therapy;
* Correct or ↓ hypoxia hypertension unstable arrhythmias;
* Carotid endarterectomy
41
Why are cardiac arrythmias common in stroke? What can reduce this risk?
* when the docs start working on the clot pieces break off and travel...;
* Translumenal procedures ↓ this risk
42
What are some anesthesia concerns for patients receiving intra-arterial thrombolysis?
* 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
What area of the aort is the most difficult to treat? Which area is easier?
* Ascending more difficult;
* Abdominal less difficult
44
What are two types of vessel abnormalities we might see on the aorta?
* Aneurysm → Dilation with 50% increase in diameter;
* Dissection → Blood enters media layer from tear in intima
45
What are two major complications for anesthesia during aorta repair surgery?
* Need to cross-clamp the aorta;
* Potential for large intraoperative blood loss
46
Related to aortic cross clamping what are some cardiac specific changes that occur?
* Acute ↑↑↑ LV afterload and severe HTN;
* Myocardial ischemia;
* LV failure;
* Aortic valve regurg
47
Related to aortic cross clamping what are some critical perfusion specific changes that occur?
* Compromises organ perfusion distal to point of occlusion;
* Interrupts BF to spinal cord and kidneys → results in paraplegia and renal failure
48
What can happen after the aortic clamp is released and why? How do we prevent this?
* 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
What are 5 indications we discussed in class for aortic surgery?
* Aneurysms;
* Aortic dissection;
* Coarctation;
* Occlusive disease;
* Trauma
50
What are the two types of coarctation of the aorta? How are they classified?
* pre-ductal (infant);
* post ductal (might not know until adult);
* Classified according to relative position WRT ductus arteriosis
51
Related to aortic surgery what are the 4 site specific lesions we need to know?
* Aortic arch;
* Ascending aorta;
* Below the diaphragm;
* Distal to left subclavian artery and above diaphragm
52
Related to aortic surgery how will we know if cardiopulmonary bypass is required?
* Lesions involving the ascending and transverse aorta require bypass
53
How are aortic dissections classified?
* DeBakey I II III;
* --OR--;
* Stanford A (proximal) or B (Distal)
54
Describe each of the DeBakey classifications?
* DeBakey I → Dissection in the ascending aorta that extends into the descending aorta;
* DeBakey II → Dissection in the ascending aorta that does not extend 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
What is an aortic dissection?
* Characterized by a spontaneous tear of the vessel wall intima permitting the passage of blood along false lumen
56
What is the most common factor contributing to the progression of an aortic dissection? Most serious complication is?
* Common factor = HTN;
* Complication = aneurysm rupture
57
Stanford classification Type A converts to DeBakey how?
* Stanford Type A = DeBakey I and II
58
How are dissecting aortic lesions treated?
* 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
Which dissecting aortic lesions have the highest incidence of rupture?
* Proximal lesions
60
What is a "True" aneurysm? What is a "False" aneurysm?
* 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
What are the 3 layers of a vessel wall?
* Tunica externa (outer);
* Tunica Media (middle);
* Tunica interna (inner)
62
What is the most common location for aortic aneurysms? What is the most common cause?
* abdominal aorta;
* atheroslcerosis or medial cystic necrosis ← he mentions both on slide 36 as being the common cause
63
What are some important complications of AAA to know?
* Depending on site:;
* aortic regurg;
* tracheal or bronchial compression or deviation;
* hemoptysis;
* superior vena cava syndrome
64
Which part of the aorta do syphalitic aneurysm generally involve?
* ascending aorta
65
What is the greatest danger of aortic aneurysm?
* rupture and exsanguination
66
What is the normal size of the aorta in adults? When would an aortic resection be performed?
* normal = 2-3 cm in width;
* Electrive resection typ done when aneurysm is > 4 cm (later he says ≥ 5-6 cm??)
67
When does a pseudoaneurysm form?
* when the intima and media are ruptured and only the adventitia or blood clot form the out layer of the vessel
68
Thromboembolic occlusion of the aorta is most commonly due to what?
* atherosclerosis;
* Combo of atheroslerotic plaque and thrombosis
69
How do we treat thromboembolic occlusion of the aorta?
* Aorto-bifemoral bypass;
* Possible proximal thromboendarterectomy
70
What are the two types of aortic trauma? What diagnostic shows you that bleeding is occurring?
* Penetrating or non-penetrating injury;
* CXR with wide mediastinum indicates bleeding
71
Why is it important to do a GOOD preop on vascular surgery patients?
* 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
Where is the most common location for a thoracic aneurysm to develop?
* Just above aortic valve distal to left subclavian takeoff → Ligamentum arteriosum
73
What are risk factors for thoracic aneurysm?
* Age;
* Aortic cannulation;
* Atherosclerosis;
* Blunt trauma;
* Crack cocaine;
* Hypertension;
* Male sex;
* Marfan's syndrome;
* Smoking
74
Why is Marfans syndrome prone to causing aneurysms?
* Vasculature can't keep up with the increased size of patients with the syndrome
75
What are the two classes of aneurysms?
* Saccular → eccentric dilation;
* Fusiform → entire circumference of aorta
76
Which class of aneurysm often occurs at the renal arteries?
* Fusiform
77
What are some S/Sx of a thoracic aneurysm?
* Often asymptomatic and but exam can find:;
* Hoarseness;
* Stridor;
* Dyspnea;
* Dysphagia;
* Dilation of aortic valve annulus
78
What are some S/Sx of acute aortic dissection?
* Severe sharp tearing pain;
* Hypotension/hypertension;
* Absence of peripheral pulses;
* Paraplegia/paraparesis
79
How do we diagnose aneurysms/aortic dissections?
* CXR;
* TEE;
* Arteriogram
80
How are aortic dissections treated?
* Stent;
* Open surgery
81
What is "anterior spinal artery syndrome"? What are some adverse S/E?
* 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
What famous artery perfuses the anterior spinal artery?
* Artery of Adamkiewicz or the greater radiculmedullary artery
83
If you notice a patient has a pulsatile abdominal mass on exam what would you suspect?
* Abdominal aneurysm → common in people > 60 y/o
84
How might we diagnose an abdominal aneurysm?
* Abdominal ultrasound;
* Helical CT - to see if endovascular repair is feasible;
* MRI
85
What is the treatment regime for abdominal aneurysms?
* <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
What are the classic S/Sx of an abdominal aneurysm rupture? What percentage of patients do these S/Sx appear?
* Hypotension;
* Back pain;
* Pulsatile mass;
* S/Sx only present in 50% of patients (hemorrhage and tamponade into retroperitoneum also happens)
87
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?
* 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
Surgery on the aortic arch and ascending aorta use what approach?
* Aortic arch → median sternotomy with deep hypothermic circulatory arrest;
* Ascending aortia → cardiopulm bypass
89
For surgery involving the aortic arch what are import considerations needed to provide the best cerebral protection?
* Know that long rewarming periods contribute to intraoperative blood loss;
* Mannitol;
* Methylprednisolone or dexamethasone;
* Narcotic infusion;
* Phenytoin;
* Systemic and topical hypothermia (15° C)
90
What is the most common location that the Artery of Adamkiewicz arises?
* T9-T12 (60% of people) → almost always on the left side
91
How do we calculate spinal cord perfusion pressure?
* Spinal Perf Pressure = MAP - SCP
92
How might we monitor for paraplegia when doing a case with aortic cross clamping?
* SSEP
93
What are some protective therapeutic measures we can take before the surgeon cross clamps the aorta?
* 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
What is ↑ renal failure following aortic surger a result of?
* Emergency procedures;
* Prolonged cross-clamp periods;
* Prolonged hypotension
