Vascular Disease Flashcards
Aortic Aneurysm needs surgery when it is over ____
5.5 cm
saccular aneurysm is a ___ shape
berry
Fusiform is a ___ dilation of the vessel
circumferential
Diagnosis of a dissection of an aneurysm by ___ is the fastest
doppler echo
Tx of aneurysm
Treatment:
Medical management to ↓expansion rate
Manage BP, Cholesterol, stop smoking
Avoid strenuous exercise, stimulants, stress
Regular monitoring for progression
Surgery indicated if >5.5 cm, growth >10mm/yr, family h/o dissection
Endovascular stent repair has become a mainstay over open surgery w/graft
AAA stent repair, CV surgeon on standby
3 Main Arterial Pathologies: ___ ____ _____
aneurysms, dissections, occlusions
______ & its branches more likely to be affected by aneurysms & dissections
______ arteries are more likely to be affected by occlusions
aorta; peripheral
Aortic aneurysm: Dilation of all _____ layers of artery, leading to a >50% increase in diameter
3
AAA stent repair is done under _____
fluoroscopy
Dissection is not a _____
rupture
Dissection: Tear in intimal layer of the vessel, causing blood to enter the medial layer
Describe Ascending dissection
Ascending dissection: Catastrophic, requires emergent surgical intervention
Stanford A, Debakey 1 & 2
Mortality increases by 1-2% per hr
Overall mortality 27-58%
Sx: Severe sharp pain in posterior chest or back
Diagnosis:
Stable= CXR, CT, MRI, Angiogram
Unstable=Echocardiogram
Stanford A, Debakey 1 & 2 describes what
aortic dissection
Stanford Class A, B
A: Ascending and descending
B: just descending
DeBakey Class 1,2,3
1: both ascending and propagates the arch
2: ascending
3: Descending
Stanford A is alway an ____ while stanford B is not
emergency
Stanford A treatment
Ascending aorta involved
Should be considered candidates for surgery
The most commonly performed procedures:
ascending aorta & aortic valve replacement w/a composite graft
ascending aorta replacement with resuspension of the aortic valve
How hypothermic do you keep a pt for stanford A surgery
Circulatory arrest at a body temp 15-18°C for 30-40 minutes can be tolerated by most pts
Stanford B treatment
Descending thoracic Aorta: An uncomplicated type B dissection with normal hemodynamics, no hematoma, and no branch vessel involvement can be treated medically
Medical therapy consists of:
1) intraarterial monitoring of SBP and UOP
If their kidneys arent being perfused they may be a candidate for surgery
2) drugs to control BP and the force of LV contraction (BBs, Cardene, SNP)
in-hospital mortality rate of 10%
long-term survival rate with medical tx is 60-80% at 5 yrs and 40-50% at 10 yrs
Surgery is indicated for type B dissection with signs of impending rupture (persistent pain, hypotension, left-sided hemothorax) or compromised perfusion to the lower body
What are the symptoms of impending rupture for a stanford B AA
persistent pain, hypotension, left-sided hemothorax
Risk factors for aortic dissection
Risk Factors: HTN, atherosclerosis, aneurysms, fam hx, cocaine use, & inflammatory diseases
Inherited disorders: Marfans, Ehlers Danlos, Bicuspid Aortic Valve
What are iatrogenic causes of AD
heart cath, aortic manipulation, cross clamping, arterial incision
What patients are the most common to have aortic dissection
men and preg women in third trimester
know that stuff
What is the symptom triad for aortic aneurysm rupture
A triad of sx seen in about ½ of cases:
Hypotension
Back pain
A pulsatile abdominal mass
Most abdominal aortic aneurysms rupture into the __ ______
left retroperitoneum
4 Primary causes of mortality r/t surgeries of thoracic aorta:
MI
Respiratory failure
Renal failure
Stroke
If __ ____ is occurring then volume resuscitation may be delayed to preserve the clot
If retroperitoneal tamponade occurs, volume resuscitation may be delayed until the rupture is surgically controlled, to maintain a lower BP and reduce risk of further bleeding, hypotension, and death
Preop Eval for AA
Assess for presence of CAD, valve dysfunction, heart failure
Ischemic heart dz may require intervention prior to surgery
Cardiac evaluation tests: stress test, echocardiogram
Low FEV1 or renal failure may preclude a pt from aortic resection —> probably will not tolerate
Smoking/COPD = predictors of post aortic surgery respiratory failure
PFTs & ABGs help define risk
Consider bronchodilators, abx, chest physiotherapy
Preop renal dysfunction is the most significant indicator of post-aortic surgery renal failure
Preop hydration: Avoid hypovolemia, HoTN & low cardiac output
Avoid nephrotoxic drugs
h/o stroke or TIA
Carotid ultrasound
Angiogram of brachiocephalic & intracranial arteries
Severe carotid stenosis→ workup for CEA before elective surgery
What is Anterior Spinal Artery Syndrome
ASA syndrome is caused by lack of blood flow to the anterior spinal artery
The anterior spinal artery perfuses the anterior ____ of the spinal cord
2/3
Ischemia of ASAS leads to:
loss motor function below the infarct
diminished pain and temperature sensation below the infarct
antonomic dysfunction, leading to hypotension and bowel & bladder dysfunction
ASA is the most common form of spinal. cord ____
ischemia
bc lack of collateral circulation
Posterior is perfused by ___ arteries
2
Common causes of ASA syndrome are….
: Aortic aneurysms, aortic dissection, atherosclerosis, trauma
Carotid disease is a prominent predictor of ____
stroke
How do you diagnosis carotid disease
Angiography- can dx vascular occlusion
CT & MRI- less invasive, may also identify aneurysms & AVMs
Transcranial doppler US- may give evidence of vascular
occlusions with real-time monitoring
Carotid auscultation- can identify bruits
Carotid US- can quantify degree of carotid stenosis
Carotid stenosis commonly occurs at the ___ _____, due to turbulent blood flow at the branch-point
carotid bifurcation
American Heart Assoc recommends TPA within ______ of onset
4.5hr
Describe the treatment of CVA
- IR
- CEA
- Carotid stenting
- Ongoing medical tx
Interventional radiology
- intra-arterial thrombolysis
- Intravascular thrombectomy *benefits seen up to 8h after onset of CVA
Carotid Endarterectomy (CEA)
- Surgical treatment for severe carotid stenosis (lumen diameter 1.5mm or >70% blockage)
Carotid stenting
- Alternative to CEA
- Major risk of microembolization→CVA
- Embolic protection devices developed to reduce risk; so far CVA risk still unchanged
Ongoing medical therapy
- Antiplatelet tx
-Smoking cessation
-BP control
-Cholesterol control
-Diet & Physical activity
Surgical treatment for severe carotid stenosis is at a lumen diameter _____ mm or ____% blockage)
1.5mm or >70%
CEA preop eval
- neuro eval and baseline
- heart disease, probably have CAD
- HTN
- CPP = MAP - ICP (so we want the MAP a little higher)
- maintain flow through cross clamping
- Extreme head rotation will compress blood flow, so dont do that
- use cerebral oximetry
Cerebral Oxygenation affected by: (5 things)
Cerebral 02 consumption affected by: (2 things)
Cerebral Oxygenation affected by:
MAP
COP
Sa02
HGB
PaC02
Cerebral 02 consumption affected by:
Temperature
Depth Anesthesia
Defined by an ankle-brachial index (ABI) <____
Acute occlusions are typically due to embolism
Atherosclerosis is systemic
Pt w/PAD have 3-5x increased risk of MI & CVA
0.9
ABI= ratio of SBP @ ankle : SBP @ brachial artery
Chronic hypo-perfusion is typically due to ______
atherosclerosis
sometimes May also be due to vasculitis
Acute occlusions are typically due to embolism
Atherosclerosis is systemic
Pt w/PAD have 3-5x increased risk of MI & CVA
Rx for PAD
diagnosis of PAD
Doppler U/S: provides a pulse volume waveform identifies arterial stenosis
Duplex U/S: can identify areas of plaque formation & calcification
Transcutaneous oximetry: can assess the severity of tissue ischemia
MRI w/contrast angiography: used to guide endovascular intervention or surgical bypass
What is the medical tx for PAD
Medical Tx: exercise, controlling BP, cholesterol, and glucose
Intervention: revascularization indicated w/disabling claudication or ischemia
Surgical reconstruction- arterial bypass procedure
Endovascular repair- angioplasty or stent placement
What are common causes of peripheral arterial occlusion
Common causes: cardiac
Left atrial thrombus d/t Afib
Left ventricular thrombus d/t cardiomyopathy after MI
For peripheral arterial occlusion what are the….
SX
DX
TX
Sx: limb ischemia, pain/paresthesia, weakness, ↓peripheral pulses, cool skin, color changes distal to occlusion
Dx: Arteriogram
Tx: anticoagulation, surgical embolectomy, amputation (last resort)
Subclavian Steal Syndrome
SC steal: occluded SCA, proximal to vertebral artery
vertebral artery flow diverts away from brainstem
Subclavian Steal Syndrome sx
Sx: Syncope, vertigo, ataxia, hemiplegia, ipsilateral arm ischemia
Effected arm SBP may be ̴20mmhg lower
Bruit over SCA
Subclavian Steal Syndrome rx
Risk Factors: atherosclerosis, h/o aortic surgery, Takayasu Arteritis
Subclavian Steal Syndrome tx
Tx: SC endarterectomy
Virchows Triad: 3 factors that predispose to venous thrombosis
Virchows Triad: 3 factors that predispose to venous thrombosis
Venous stasis
Disrupted vascular endothelium
Hypercoagulability
Risk factors for DVT
risk factors: >age 40, surgery >1h, cancer, ortho surgeries on pelvis & LEs, abdominal surgery
Half of all hip replacements will result in ____ that will resolve on their own
50%
How do you treat a DVT
Anticoagulation: Warfarin + Heparin or LMWH
- LMWH advantages over unfractionated heparin
- longer HL & more predictable dose response
- doesn’t require serial assessment of aPTT
- Less risk of bleeding
LMWH disadvantages
-Higher cost
L-ack of reversal agent
Warfarin (vit K antagonist) is initiated during heparin treatment and adjusted to achieve INR btw 2-3
Heparin discontinued when Warfarin achieves therapeutic effect
PO anticoagulants continued 6 months or longer
IVC filter may be indicated w/ recurrent PE, or contraindication to anticoagulants
what is systemic vasculitis
Group of vascular inflammatory diseases catagorized by the size of the vessels at the primary site of the abnormality
Large-artery vasculitis includes: 2
Medium-artery vasculitis includes: 1
Medium to small-artery vasculitis includes: 3
Large-artery vasculitis includes:
Takayasu arteritis
Temporal (or giant cell) arteritis
Medium-artery vasculitis includes:
Kawasaki disease, which usually affects the coronary arteries
Medium to small-artery vasculitis includes:
Thromboangiitis obliterans
Wegener granulomatosis
Polyarteritis nodosa
Temporal (or giant cell) arteritis sx,dx,tx
buergers disease is …..
Inflammatory vasculitis leading to small & medium vessel occlusions in the extremities
buergers disease is mainly triggered by _____ and in ____ under 45
smoking; under
the main vessel with issues in buergers disease is …..
infrapopliteal arterial occlusive dz
Polyarteritis Nodosa is….
Vasculitis of the small and medium vessels
Polyarteritis Nodosa leads to what 4 things
Leads to glomerulonephritis, myocardial ischemia, peripheral neuropathy and seizures
Lower Extremity Chronic Venous Disease risk factors
Risk factors:
advanced age
family hx
pregnancy
ligamentous laicity
previous venous thrombosis
LE injuries
prolonged standing
obesity
smoking
sedentary lifestyle
high estrogen levels
Lower Extremity Chronic Venous Disease diagnostic criteria
Diagnostic criteria: Sx of leg pain, heaviness, fatigue
Confirmed by ultrasound showing venous reflux
Retrograde blood flow > 0.5 seconds
