Vascular Disease COPY Flashcards
1
Q
What are the 3 main arterial pathologies in vascular disease?
A
Aneurysms, dissections, occlusions
2
Q
Which arteries are more likely to be affected by aneurysms and dissections?
A
Aorta & its branches
3
Q
Which arteries are more likely to be affected by occlusions?
A
Peripheral arteries
4
Q
What is an aortic aneurysm characterized by?
A
Dilation of all 3 layers of artery
5
Q
What diameter increase in an artery constitutes an aortic aneurysm?
A
> 50%
6
Q
At what diameter is surgery indicated for aortic aneurysm?
A
> 5.5 cm
7
Q
What is the mortality rate associated with aortic aneurysm rupture?
A
75%
8
Q
What are the 2 types of aortic aneurysms?
A
Fusiform and Saccular
9
Q
How does a fusiform aortic aneurysm appear?
A
Uniform dilation along entire circumference
10
Q
How does a saccular aortic aneurysm appear?
A
Berry-shaped bulge to one side
11
Q
What are some diagnostic tools for aortic aneurysms?
A
CT, MRI, CXR, Angiogram, Echocardiogram
12
Q
Which imaging modality is the fastest/safest in suspected aortic dissection?
A
Doppler echocardiogram
13
Q
What are the treatment options for aortic aneurysms?
A
Medical management, surgery if criteria met
14
Q
What are lifestyle modifications would you implement for aortic aneurysm?
A
- manage BP/cholesterol
- stop smoking
- avoid strenuous exercise/stress
- avoid stimulants
15
Q
When is surgery indicated for aortic aneurysms?
A
> 5.5 cm, growth >10mm/yr, family history of dissection
16
Q
What is the mainstay treatment over open surgery for aortic aneurysms?
A
Endovascular stent repair
17
Q
What is aortic dissection?
A
Tear in intimal layer of the vessel, causing blood to enter the medial layer
18
Q
What type of aortic dissection requires emergent surgical intervention?
A
Ascending dissection
19
Q
What are the mortality rates associated with aortic ascending dissection?
A
Overall mortality 27-58% (ascending dissection)
20
Q
What are the diagnostic tools for stable aortic dissection? Unstable?
A
Stable: CT, CXR, MRI, Angiogram
Unstable: Doppler echocardiogram (fastest)
21
Q
What main symptom is associated with aortic dissection?
A
severe sharp pain in posterior chest or back
22
Q
Ascending Dissection: Mortality increases by __ per __
A
1-2% per hour
23
Q
What are the classes for aortic aneurysm-dissection?
A
Stanford Class A, B; DeBakey Class 1,2,3
24
Q
What is the characteristic of a Stanford A aortic dissection classification?
A
tear in the ascending aorta
25
What is the characteristic of a Stanford B aortic dissection classification?
tear in the descending aorta
26
What are characteristics of DeBakey I, II, and III?
I: tear in ascending aorta, propogates to arch
II: tear confined to ascending aorta
III: tear in descending aorta
27
What should be considered for all patients with acute dissection involving the ascending aorta?
Surgery
28
What are the most commonly performed procedures for acute dissection involving the ascending aorta?
Replacement of aorta and aortic valve
29
What surgery techniques are utilized for aortic arch dissection surgery?
* circulatory arrest 30-40 min
* profound hypothermia (15-18º)
* cardiopulmonary bypass
30
How can patients with an acute, uncomplicated type B aortic dissection be treated?
Medical therapy
31
What does medical therapy for type B aortic dissection involve?
Intraarterial monitoring of SBP, UOP, drugs for BP control
32
What is the in-hospital mortality rate for patients with uncomplicated type B aortic dissection treated with medical therapy?
10%
33
What is the long-term survival rate at 5 years for patients with medical therapy only for type B aortic dissection? 10 years?
5 yr: 60-80%
10 yr: 40-50%
34
When is surgery indicated for patients with type B aortic dissection?
Signs of impending rupture (persistent pain, HoTN, left hemothorax), ischemia of legs, spinal cord, & organ failure
35
What is the in-hospital mortality rate associated with surgical treatment of distal aortic dissection?
29%
36
How are ascending aortic arch dissections typically treated?
Emergent surgery
37
How are descending arch aortic dissections usually treated?
Rarely with urgent surgery
38
What is the management approach for uncomplicated type B aortic dissections?
Admitted for BP control
39
What symptoms may indicate an impending rupture of an aortic dissection?
Posterior pain, HoTN, Left side hemothorax
40
What are risk factor for aortic dissections? (6)
HTN
atherosclerosis
aneurysms
fam history
cocaine use
inflammatory disease
41
Name two inherited disorders that increase the risk for aortic dissections.
Marfan's, Ehlers-Danlos
42
When is dissection more common in pregnant women?
3rd trimester
43
What are iatrogenic causes of aortic dissection related to?
Cardiac catheterization, aortic manipulation, cross clamping & arterial incision
44
What are the predisposing factors for aortic aneurysm?
HTN, atherosclerosis, age, male, smoking, family history
45
What are the common symptoms of aortic aneurysm?
May be asymptomatic or present with pain from compression
46
When is elective surgical repair recommended for aortic aneurysm?
Diameter >6 cm or rapidly enlarging aneurysms
47
What is the preferred management for aortic aneurysm patients at high risk?
Endovascular repair
48
What is the typical presentation of aortic dissection?
Severe sharp pain in the posterior chest or back
49
How is Type A aortic dissection managed?
Acute surgical emergency
50
How is Type B aortic dissection managed?
If uncomplicated, medical management can be pursued
51
What triad of symptoms is experienced in about half of aortic aneurysm rupture cases?
Hypotension, back pain, pulsatile abdominal mass
52
Where do most abdominal aortic aneurysms rupture into?
Left retroperitoneum
53
Why may exsanguination be prevented in aortic aneurysm ruptures?
Clotting and tamponade effect in the retroperitoneum
54
What should be deferred until the rupture is surgically controlled in aortic aneurysm ruptures?
Euvolemic resuscitation
55
Why can euvolemic resuscitation without controlling bleeding be dangerous in aortic aneurysm ruptures?
May lead to loss of tamponade, further bleeding, hypotension, death
56
What is required for patients in unstable condition with suspected ruptured abdominal aortic aneurysm?
Immediate operation without preoperative testing or volume resuscitation
57
What are the 4 primary causes of mortality related to surgeries of the thoracic aorta?
MI, Respiratory failure, Renal failure, Stroke
58
What tests are included in a cardiac evaluation on the thoracic aorta?
stress test, echo, radionuclide imaging
59
What conditions may preclude a patient from AAA resection?
Severe reduction in FEV1 or renal failure
60
What are predictors of post-aortic surgery respiratory failure?
Smoking/COPD
61
What can be considered to help prevent post-aortic surgery respiratory complications?
bronchodilators, abx, chest physiotherapy
62
What is the most important indicator of post-aortic surgery renal failure?
Preop renal dysfunction
63
What should be avoided preoperatively to prevent renal failure?
Hypovolemia, HoTN & low cardiac output
64
What type of drugs should be avoided preoperatively?
Nephrotoxic drugs
65
What is recommended for patients with severe carotid stenosis?
Workup for CEA before elective surgery
66
What is anterior spinal artery syndrome?
Lack of blood flow to anterior spinal artery
67
What does the anterior spinal artery perfuse?
Anterior 2/3 of spinal cord
68
What are the consequences of ischemia in anterior spinal artery syndrome?
Loss of motor function, diminished pain/temp sensation, autonomic dysfunction
69
Why is anterior spinal artery syndrome the most common form of spinal cord ischemia?
Minimal collateral perfusion
70
How is the posterior spinal cord different in terms of perfusion?
Perfused by two posterior spinal arteries (better collateral)
71
What are some common causes of anterior spinal artery syndrome?
Aortic aneurysm, aortic dissection, atherosclerosis, trauma
72
What are the two main types of Cerebral Vascular Accidents?
Ischemic (87%) and Hemorrhagic (13%)
73
What is a significant predictor of CVA?
Carotid dz
74
What is the 1st leading cause of disability in the US?
CVA
75
TIA is a subset of what?
Self-limited ischemic strokes
76
What is the usual timeframe for symptoms to resolve in TIA?
Within 24h
77
How much greater is the risk of subsequent stroke in individuals who had a TIA?
10x
78
What diagnostic test can identify vascular occlusion in carotid disease?
Angiography
79
What are inherited risk factors for stroke? (5)
age
Male
Black race
hx stroke
sickle cell
80
What are modifiable risk factors for stroke? (8)
HTN
smoking
diabetes
carotid disease
afib
HF
↑Cholesterol
obesity
81
What carotid diagnostic tests are less invasive options for carotid disease and may identify aneurysms and AVMs?
CT & MRI
82
Which diagnostic test can provide indirect evidence of vascular occlusions with real-time bedside monitoring in carotid disease?
Transcranial doppler US
83
What can carotid auscultation identify in carotid disease?
Bruits
84
Where does carotid stenosis commonly occur due to turbulent blood flow at the branch-point?
Internal/external carotid bifurcation
85
What should the workup for carotid disease include evaluating for as potential sources of emboli?
A-fib, heart failure, valvular vegetation, or paradoxical emboli in the setting of PFO
86
What does the AHA recommend for the TPA treatment of CVA?
TPA within 4.5 hours
87
What is a surgical option for severe carotid stenosis?
Carotid Endarterectomy (CEA)
88
What are alternatives to Carotid Endarterectomy?
* Carotid stenting
* Interventional radiology (thrombolysis, thrombectomy)
89
What are some components of ongoing medical therapy for treating CVA? (5)
Antiplatelet tx
Smoking cessation
BP control
Cholesterol control
Diet & Physical activity
90
What is the importance of establishing preoperative deficits in patients undergoing carotid endarterectomy (CEA)?
Helps in neurologic evaluation
91
Why is monitoring blood pressure important during CEA surgery?
Optimizes cerebral perfusion pressure
92
What should be considered when a patient has severe carotid artery disease along with severe coronary artery disease?
most compromied area should take priority
93
What factors can affect cerebral oxygenation according to the text?
MAP
COP
SaO2
HGB
PaCO2
94
What 2 factors can affect cerebral oxygen consumption?
Temperature, Anesthesia
95
What does Peripheral Artery Disease result in?
Compromised blood flow to extremities
96
How is Peripheral Artery Disease defined?
ankle-brachial index (ABI) <0.9
97
What is the ankle-brachial index (ABI)?
Ratio of SBP @ ankle : SBP @ brachial artery
98
What is chronic hypo-perfusion in PAD typically due to?
Atherosclerosis
99
What are acute occlusions in PAD typically due to?
Embolism
100
How does the incidence of PAD change with age?
Increases, exceeding 70% by age 75
101
What is the risk of MI & CVA in patients with PAD compared to general population?
3-5x increased risk
102
What are the risk factors for Peripheral Artery Disease? (7)
Advanced age
Family hx
Smoking
DM
HTN
Obesity
↑ cholesterol
103
What are some signs and symptoms of Peripheral Artery Disease? (7)
Intermittent claudication, Resting extremity pain, Decreased pulses, Subcutaneous atrophy, Hair loss, Coolness, Cyanosis
104
How can relief be achieved for symptoms of Peripheral Artery Disease?
Relief with hanging lower extremity over side of bed (increases hydrostatic pressure)
105
What does Doppler U/S provide and identify in the diagnosis of Peripheral Artery Disease?
Pulse volume waveform identifies arterial stenosis
106
What can Duplex U/S identify in the diagnosis of Peripheral Artery Disease?
Plaque formation, calcification
107
How can Transcutaneous oximetry help in diagnosing Peripheral Artery Disease?
Assess tissue ischemia severity
108
What is the role of MRI w/contrast angiography in Peripheral Artery Disease management?
Guide endovascular intervention
109
What are the 4 components of Medical Tx for Peripheral Artery Disease?
Exercise, BP, cholesterol, glucose control
110
When is revascularization indicated in Peripheral Artery Disease?
Disabling claudication or ischemia
111
What surgical procedures are used for revascularization in Peripheral Artery Disease?
Arterial bypass, endovascular repair
112
What are common causes of acute artery occlusion? (2)
Left atrial thrombus (afib), left ventricular thrombus (post MI)
113
What are less common thrombus causes of acute artery occlusion? (3)
Valvular heart disease, endocarditis, PFO
114
What are noncardiac causes of acute artery occlusion? (4)
Atheroemboli, plaque rupture, hypercoagulability, trauma
115
What are the symptoms of acute artery occlusion? (6)
Limb ischemia
pain/paresthesia
weakness
decreased peripheral pulses
cool skin
color changes distal to occlusion
116
How is acute artery occlusion diagnosed?
Arteriography
117
What is the treatment for acute artery occlusion?
Surgical embolectomy, anticoagulation, amputation (last resort)
118
What is Subclavian Steal Syndrome?
Occluded SCA causing vertebral artery blood flow diversion from brain stem
119
What are the symptoms of Subclavian Steal Syndrome? (5)
Syncope
vertigo
ataxia
hemiplegia
ipsilateral arm ischemia
120
What are 3 risk factors for Subclavian Steal Syndrome?
**Atherosclerosis**
Takayasu arteritis
Aortic surgery
121
What is the curative treatment for Subclavian Steal Syndrome?
SC endarterectomy
122
What 2 assessment findings might be associated with subclavian steal syndrome?
Affected arm SBP ↓20mmHg
Bruit over SCA
123
What is Raynaud's Phenomenon?
Episodic vasospastic ischemia of the digits
124
Who does Raynaud's Phenomenon affect more, women or men?
affects women > men
125
What are some symptoms of Raynaud's Phenomenon?
Digital blanching or cyanosis w/cold exposure or SNS activation
126
How is Raynaud's Phenomenon diagnosed?
Based on history & physical
127
What are 3 treatment options for Raynaud's Phenomenon?
Protection from cold
CCBs
alpha-blockers
128
In which cases is surgical sympathectomy considered for Raynaud's Phenomenon?
For severe ischemia
129
What are 3 common PVD processes that can occur during surgery?
Superficial thrombophlebitis
Deep vein thrombosis
Chronic venous insufficiency
130
Why is DVT a major concern during surgery?
Can lead to PE, a leading cause of perioperative M & M
131
What are the 3 major factors of Virchow's Triad that predispose to venous thrombosis?
Venous stasis
Hypercoagulability
Disrupted vascular endothelium
132
Superficial thombophlebitis and DVT occur in approximately 50% of what kind of surgery?
total hip replacement
133
What are some risk factors for DVT? (5)
>age 40
surgery >1h
cancer
ortho surgeries on pelvis & LEs
abdominal surgery
134
What 3 diagnostic tools are useful for detecting thrombosis?
Doppler U/S
Venography
Impedance plethysmography
135
What prophylactic measures can be taken to prevent thrombosis?
SCD’s
SQ heparin 2-3x/day
Regional anesthesia (d/t early ambulation)
136
What are some moderate-risk medical conditions for developing deep vein thrombosis?
postpartum period
MI
CHF
137
What are some high-risk factors for developing deep vein thrombosis?
Hx thombosis, stroke
Extensive trauma
Major fractures
Knee or hip replacement
138
What are the recommended steps to minimize deep vein thrombosis?
Compression stockings
Early ambulation
anticoagulants
IVC
139
How can deep vein thrombosis be diagnosed?
Compression ultrasonography or impedance plethysmography
140
What should be done if deep vein thrombosis is suspected but US is normal?
Repeat imaging on days 2 and 7
141
When can deep vein thrombosis be ruled out?
If no abnormalities are found on US and normal repeat US
142
Which anticoagulants are used for Deep Vein Thrombosis (DVT) treatment?
Warfarin + Heparin or LMWH
143
What are the advantages of LMWH over unfractionated heparin?
* Longer half-life
* more predictable dose response
* doesnt require serial aPTT
* Less risk of bleeding
144
What are the disadvantages of LMWH?
* higher cost
* no reversal agent
145
What is the recommended INR range when Warfarin is used for DVT treatment?
INR between 2-3
146
How long are PO anticoagulants typically continued after a DVT?
6 months or longer
147
In what situations may an IVC filter be placed for DVT patients?
Recurrent PE or contraindication to anticoagulants
148
What are the 2 main types of large-artery vasculitis?
Takayasu arteritis
Temporal (giant cell) arteritis
149
What is the primary vessel affected in Kawasaki disease?
Coronary arteries
150
What are examples of medium to small-artery vasculitis?
Thromboangiitis obliterans, Wegener granulomatosis, Polyarteritis nodosa
151
What is temporal (giant cell) arteritis?
Inflammation of arteries of the head and neck
152
What are the symptoms of temporal arteritis?
Unilateral: headache, scalp tenderness, jaw claudication
153
Why is prompt initiation of corticosteroids indicated in temporal arteritis visual symptoms?
To prevent blindness
154
How is temporal arteritis diagnosed?
Biopsy of temporal artery shows arteritis in 90% of patients
155
What is Thromboangiitis Obliterans also known as?
Buerger Disease
156
What is Thromboangiitis Obliterans?
autoimmune inflammatory vasculitis ⇒ small/medium vessel occlusion in extremities
157
What triggers the autoimmune response in Buerger Disease?
Nicotine
158
What is the most predisposing factor for Buerger Disease?
Tobacco use
159
Who is Buerger Disease most prevalent in?
Men <45
160
What are the 5 diagnostic criteria for Buerger Disease?
* Hx smoking
* onset before 50
* infrapopliteal arterial occlusive disease
* upper limb involvement
* absence of risk factors for atherosclerosis
161
How is the diagnosis of Buerger Disease confirmed?
Biopsy of vascular lesions
162
What are the symptoms of Thromboangiitis Obliterans 'Buerger Disease'?
* forearm, calf, foot claudication
* Ischemia of hands & feet
* Ulceration and skin necrosis
* Raynaud's
163
What is considered the most effective treatment for Thromboangiitis Obliterans 'Buerger Disease'?
Smoking cessation
164
What are the anesthesia implications for Thromboangiitis Obliterans 'Buerger Disease'?
Meticulous positioning/padding
Avoid cold ⇒ Warm room
Prefer non-invasive BP
Conservative line placement
165
What is Polyarteritis Nodosa?
Antineutrophyl cytoplasmic antibody (ANCA) negative vasculitis
166
What are possible associations of Polyarteritis Nodosa?
Hepatitis B, Hepatitis C, Hairy Cell Leukemia
167
What are some complications of Polyarteritis Nodosa?
Glomerulonephritis
myocardial ischemia
peripheral neuropathy
seizures
168
What is the primary cause of death in Polyarteritis Nodosa?
Renal failure
169
How is Polyarteritis Nodosa treated?
Steroids, cyclophosphamide, treating underlying cause
170
What coexisting conditions should anesthesia consider in Polyarteritis Nodosa patients?
Renal disease, cardiac disease, hypertension
171
What are 2 mild symptoms of lower extremity chronic venous disease?
Telangiectasias, varicose veins
172
What are 3 severe symptoms of lower extremity chronic venous disease?
Edema, skin changes, ulceration
173
What are some risk factors for lower extremity chronic venous disease?
Advanced age
family hx
pregnancy
obesity
smoking
prolonged standing
174
What are the diagnostic criteria for Lower Extremity Chronic Venous Insufficiency?
Leg pain, heaviness, fatigue. Ultrasound showing venous reflux.
175
What is the initial treatment for Lower Extremity Chronic Venous Insufficiency?
Leg elevation
exercise
weight loss
compression therapy
skin barriers/emollients
steroids
wound management.
176
What are some conservative medical management options for Lower Extremity Chronic Venous Disease?
Diuretics
Aspirin
Antibiotics
Prostacyclin analogues
Zinc sulfate
177
When can ablation be considered for Lower Extremity Chronic Venous Disease?
If medical management fails
178
What are the methods of ablation for Chronic Venous Disease?
Thermal ablation w/laser, Radiofrequency ablation, Endovenous laser ablation, Sclerotherapy
179
What are the indications for ablation in Chronic Venous Disease?
Venous hemorrhage, Thrombophlebitis, Symptomatic venous reflux
180
What are the contraindications for ablation in Chronic Venous Disease?
Pregnancy, Thrombosis, PAD, Limited mobility, Congenital venous abnormalities
181
What are some surgical interventions for Lower Extremity Chronic Venous Disease?
Saphenous vein inversion
High saphenous ligation
Ambulatory Phlebectomy
Transilluminated-powered phlebectomy
Venous ligation
Perforator ligation
182
What is the leading cause of perioperative morbidity and mortality in noncardiac surgery?
Cardiac complications
183
Which group of patients has a higher incidence of cardiac complications during surgery?
Patients undergoing vascular surgery
184
In patients with peripheral arterial disease, what is their increased risk of cardiovascular ischemic events compared to those without?
3-5 times greater risk
185
What luminal diameter percentage represents significant stenosis in the carotid artery based on studies?
70-75%
(1.5 mm or >70%)
186
What can occur if collateral cerebral blood flow is inadequate in carotid artery stenosis?
TIAs and ischemic infarction
187
What blood pressure abnormalities can be observed during and after carotid endarterectomy?
Hypertension and hypotension
188
What is the typical cause of acute arterial occlusion?
Cardiogenic embolism
189
What can cause cardiogenic embolism?
Thrombus in the left ventricle due to MI or dilated cardiomyopathy
190
List some cardiac causes of systemic emboli.
Valvular heart disease, prosthetic heart valves, infective endocarditis, left atrial myxoma, Afib, atheroemboli
191
What is Thromboangiitis obliterans?
An inflammatory vasculitis leading to occlusion of small and medium-sized arteries and veins in the extremities
192
What prophylactic measures do patients at low risk for DVT require?
Early ambulation, compression stockings
193
Which patients may have a higher risk of DVT?
>40 y/o
surgery >1 hour
LE orthopedic
pelvic or abdominal surgery
Prolonged bedrest
194
What is an improvement seen with endovascular repair of aortic lesions?
Significant perioperative mortality improvement
