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24 Physical & Health Assessment > Vascular Disease COPY > Flashcards

Vascular Disease COPY Flashcards

1
Q

What are the 3 main arterial pathologies in vascular disease?

A

Aneurysms, dissections, occlusions

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2
Q

Which arteries are more likely to be affected by aneurysms and dissections?

A

Aorta & its branches

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3
Q

Which arteries are more likely to be affected by occlusions?

A

Peripheral arteries

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4
Q

What is an aortic aneurysm characterized by?

A

Dilation of all 3 layers of artery

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5
Q

What diameter increase in an artery constitutes an aortic aneurysm?

A

> 50%

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6
Q

At what diameter is surgery indicated for aortic aneurysm?

A

> 5.5 cm

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7
Q

What is the mortality rate associated with aortic aneurysm rupture?

A

75%

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8
Q

What are the 2 types of aortic aneurysms?

A

Fusiform and Saccular

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9
Q

How does a fusiform aortic aneurysm appear?

A

Uniform dilation along entire circumference

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10
Q

How does a saccular aortic aneurysm appear?

A

Berry-shaped bulge to one side

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11
Q

What are some diagnostic tools for aortic aneurysms?

A

CT, MRI, CXR, Angiogram, Echocardiogram

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12
Q

Which imaging modality is the fastest/safest in suspected aortic dissection?

A

Doppler echocardiogram

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13
Q

What are the treatment options for aortic aneurysms?

A

Medical management, surgery if criteria met

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14
Q

What are lifestyle modifications would you implement for aortic aneurysm?

A
  • manage BP/cholesterol
  • stop smoking
  • avoid strenuous exercise/stress
  • avoid stimulants
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15
Q

When is surgery indicated for aortic aneurysms?

A

> 5.5 cm, growth >10mm/yr, family history of dissection

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16
Q

What is the mainstay treatment over open surgery for aortic aneurysms?

A

Endovascular stent repair

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17
Q

What is aortic dissection?

A

Tear in intimal layer of the vessel, causing blood to enter the medial layer

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18
Q

What type of aortic dissection requires emergent surgical intervention?

A

Ascending dissection

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19
Q

What are the mortality rates associated with aortic ascending dissection?

A

Overall mortality 27-58% (ascending dissection)

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20
Q

What are the diagnostic tools for stable aortic dissection? Unstable?

A

Stable: CT, CXR, MRI, Angiogram

Unstable: Doppler echocardiogram (fastest)

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21
Q

What main symptom is associated with aortic dissection?

A

severe sharp pain in posterior chest or back

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22
Q

Ascending Dissection: Mortality increases by __ per __

A

1-2% per hour

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23
Q

What are the classes for aortic aneurysm-dissection?

A

Stanford Class A, B; DeBakey Class 1,2,3

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24
Q

What is the characteristic of a Stanford A aortic dissection classification?

A

tear in the ascending aorta

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25
Q

What is the characteristic of a Stanford B aortic dissection classification?

A

tear in the descending aorta

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26
Q

What are characteristics of DeBakey I, II, and III?

A

I: tear in ascending aorta, propogates to arch

II: tear confined to ascending aorta

III: tear in descending aorta

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27
Q

What should be considered for all patients with acute dissection involving the ascending aorta?

A

Surgery

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28
Q

What are the most commonly performed procedures for acute dissection involving the ascending aorta?

A

Replacement of aorta and aortic valve

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29
Q

What surgery techniques are utilized for aortic arch dissection surgery?

A
  • circulatory arrest 30-40 min
  • profound hypothermia (15-18º)
  • cardiopulmonary bypass
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30
Q

How can patients with an acute, uncomplicated type B aortic dissection be treated?

A

Medical therapy

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31
Q

What does medical therapy for type B aortic dissection involve?

A

Intraarterial monitoring of SBP, UOP, drugs for BP control

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32
Q

What is the in-hospital mortality rate for patients with uncomplicated type B aortic dissection treated with medical therapy?

A

10%

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33
Q

What is the long-term survival rate at 5 years for patients with medical therapy only for type B aortic dissection? 10 years?

A

5 yr: 60-80%

10 yr: 40-50%

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34
Q

When is surgery indicated for patients with type B aortic dissection?

A

Signs of impending rupture (persistent pain, HoTN, left hemothorax), ischemia of legs, spinal cord, & organ failure

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35
Q

What is the in-hospital mortality rate associated with surgical treatment of distal aortic dissection?

A

29%

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36
Q

How are ascending aortic arch dissections typically treated?

A

Emergent surgery

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37
Q

How are descending arch aortic dissections usually treated?

A

Rarely with urgent surgery

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38
Q

What is the management approach for uncomplicated type B aortic dissections?

A

Admitted for BP control

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39
Q

What symptoms may indicate an impending rupture of an aortic dissection?

A

Posterior pain, HoTN, Left side hemothorax

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40
Q

What are risk factor for aortic dissections? (6)

A

HTN
atherosclerosis
aneurysms
fam history
cocaine use
inflammatory disease

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41
Q

Name two inherited disorders that increase the risk for aortic dissections.

A

Marfan’s, Ehlers-Danlos

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42
Q

When is dissection more common in pregnant women?

A

3rd trimester

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43
Q

What are iatrogenic causes of aortic dissection related to?

A

Cardiac catheterization, aortic manipulation, cross clamping & arterial incision

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44
Q

What are the predisposing factors for aortic aneurysm?

A

HTN, atherosclerosis, age, male, smoking, family history

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45
Q

What are the common symptoms of aortic aneurysm?

A

May be asymptomatic or present with pain from compression

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46
Q

When is elective surgical repair recommended for aortic aneurysm?

A

Diameter >6 cm or rapidly enlarging aneurysms

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47
Q

What is the preferred management for aortic aneurysm patients at high risk?

A

Endovascular repair

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48
Q

What is the typical presentation of aortic dissection?

A

Severe sharp pain in the posterior chest or back

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49
Q

How is Type A aortic dissection managed?

A

Acute surgical emergency

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50
Q

How is Type B aortic dissection managed?

A

If uncomplicated, medical management can be pursued

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51
Q

What triad of symptoms is experienced in about half of aortic aneurysm rupture cases?

A

Hypotension, back pain, pulsatile abdominal mass

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52
Q

Where do most abdominal aortic aneurysms rupture into?

A

Left retroperitoneum

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53
Q

Why may exsanguination be prevented in aortic aneurysm ruptures?

A

Clotting and tamponade effect in the retroperitoneum

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54
Q

What should be deferred until the rupture is surgically controlled in aortic aneurysm ruptures?

A

Euvolemic resuscitation

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55
Q

Why can euvolemic resuscitation without controlling bleeding be dangerous in aortic aneurysm ruptures?

A

May lead to loss of tamponade, further bleeding, hypotension, death

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56
Q

What is required for patients in unstable condition with suspected ruptured abdominal aortic aneurysm?

A

Immediate operation without preoperative testing or volume resuscitation

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57
Q

What are the 4 primary causes of mortality related to surgeries of the thoracic aorta?

A

MI, Respiratory failure, Renal failure, Stroke

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58
Q

What tests are included in a cardiac evaluation on the thoracic aorta?

A

stress test, echo, radionuclide imaging

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59
Q

What conditions may preclude a patient from AAA resection?

A

Severe reduction in FEV1 or renal failure

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60
Q

What are predictors of post-aortic surgery respiratory failure?

A

Smoking/COPD

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61
Q

What can be considered to help prevent post-aortic surgery respiratory complications?

A

bronchodilators, abx, chest physiotherapy

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62
Q

What is the most important indicator of post-aortic surgery renal failure?

A

Preop renal dysfunction

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63
Q

What should be avoided preoperatively to prevent renal failure?

A

Hypovolemia, HoTN & low cardiac output

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64
Q

What type of drugs should be avoided preoperatively?

A

Nephrotoxic drugs

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65
Q

What is recommended for patients with severe carotid stenosis?

A

Workup for CEA before elective surgery

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66
Q

What is anterior spinal artery syndrome?

A

Lack of blood flow to anterior spinal artery

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67
Q

What does the anterior spinal artery perfuse?

A

Anterior 2/3 of spinal cord

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68
Q

What are the consequences of ischemia in anterior spinal artery syndrome?

A

Loss of motor function, diminished pain/temp sensation, autonomic dysfunction

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69
Q

Why is anterior spinal artery syndrome the most common form of spinal cord ischemia?

A

Minimal collateral perfusion

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70
Q

How is the posterior spinal cord different in terms of perfusion?

A

Perfused by two posterior spinal arteries (better collateral)

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71
Q

What are some common causes of anterior spinal artery syndrome?

A

Aortic aneurysm, aortic dissection, atherosclerosis, trauma

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72
Q

What are the two main types of Cerebral Vascular Accidents?

A

Ischemic (87%) and Hemorrhagic (13%)

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73
Q

What is a significant predictor of CVA?

A

Carotid dz

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74
Q

What is the 1st leading cause of disability in the US?

A

CVA

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75
Q

TIA is a subset of what?

A

Self-limited ischemic strokes

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76
Q

What is the usual timeframe for symptoms to resolve in TIA?

A

Within 24h

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77
Q

How much greater is the risk of subsequent stroke in individuals who had a TIA?

A

10x

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78
Q

What diagnostic test can identify vascular occlusion in carotid disease?

A

Angiography

79
Q

What are inherited risk factors for stroke? (5)

A

age
Male
Black race
hx stroke
sickle cell

80
Q

What are modifiable risk factors for stroke? (8)

A

HTN
smoking
diabetes
carotid disease
afib
HF
↑Cholesterol
obesity

81
Q

What carotid diagnostic tests are less invasive options for carotid disease and may identify aneurysms and AVMs?

A

CT & MRI

82
Q

Which diagnostic test can provide indirect evidence of vascular occlusions with real-time bedside monitoring in carotid disease?

A

Transcranial doppler US

83
Q

What can carotid auscultation identify in carotid disease?

A

Bruits

84
Q

Where does carotid stenosis commonly occur due to turbulent blood flow at the branch-point?

A

Internal/external carotid bifurcation

85
Q

What should the workup for carotid disease include evaluating for as potential sources of emboli?

A

A-fib, heart failure, valvular vegetation, or paradoxical emboli in the setting of PFO

86
Q

What does the AHA recommend for the TPA treatment of CVA?

A

TPA within 4.5 hours

87
Q

What is a surgical option for severe carotid stenosis?

A

Carotid Endarterectomy (CEA)

88
Q

What are alternatives to Carotid Endarterectomy?

A
  • Carotid stenting
  • Interventional radiology (thrombolysis, thrombectomy)
89
Q

What are some components of ongoing medical therapy for treating CVA? (5)

A

Antiplatelet tx
Smoking cessation
BP control
Cholesterol control
Diet & Physical activity

90
Q

What is the importance of establishing preoperative deficits in patients undergoing carotid endarterectomy (CEA)?

A

Helps in neurologic evaluation

91
Q

Why is monitoring blood pressure important during CEA surgery?

A

Optimizes cerebral perfusion pressure

92
Q

What should be considered when a patient has severe carotid artery disease along with severe coronary artery disease?

A

most compromied area should take priority

93
Q

What factors can affect cerebral oxygenation according to the text?

A

MAP
COP
SaO2
HGB
PaCO2

94
Q

What 2 factors can affect cerebral oxygen consumption?

A

Temperature, Anesthesia

95
Q

What does Peripheral Artery Disease result in?

A

Compromised blood flow to extremities

96
Q

How is Peripheral Artery Disease defined?

A

ankle-brachial index (ABI) <0.9

97
Q

What is the ankle-brachial index (ABI)?

A

Ratio of SBP @ ankle : SBP @ brachial artery

98
Q

What is chronic hypo-perfusion in PAD typically due to?

A

Atherosclerosis

99
Q

What are acute occlusions in PAD typically due to?

A

Embolism

100
Q

How does the incidence of PAD change with age?

A

Increases, exceeding 70% by age 75

101
Q

What is the risk of MI & CVA in patients with PAD compared to general population?

A

3-5x increased risk

102
Q

What are the risk factors for Peripheral Artery Disease? (7)

A

Advanced age
Family hx
Smoking
DM
HTN
Obesity
↑ cholesterol

103
Q

What are some signs and symptoms of Peripheral Artery Disease? (7)

A

Intermittent claudication, Resting extremity pain, Decreased pulses, Subcutaneous atrophy, Hair loss, Coolness, Cyanosis

104
Q

How can relief be achieved for symptoms of Peripheral Artery Disease?

A

Relief with hanging lower extremity over side of bed (increases hydrostatic pressure)

105
Q

What does Doppler U/S provide and identify in the diagnosis of Peripheral Artery Disease?

A

Pulse volume waveform identifies arterial stenosis

106
Q

What can Duplex U/S identify in the diagnosis of Peripheral Artery Disease?

A

Plaque formation, calcification

107
Q

How can Transcutaneous oximetry help in diagnosing Peripheral Artery Disease?

A

Assess tissue ischemia severity

108
Q

What is the role of MRI w/contrast angiography in Peripheral Artery Disease management?

A

Guide endovascular intervention

109
Q

What are the 4 components of Medical Tx for Peripheral Artery Disease?

A

Exercise, BP, cholesterol, glucose control

110
Q

When is revascularization indicated in Peripheral Artery Disease?

A

Disabling claudication or ischemia

111
Q

What surgical procedures are used for revascularization in Peripheral Artery Disease?

A

Arterial bypass, endovascular repair

112
Q

What are common causes of acute artery occlusion? (2)

A

Left atrial thrombus (afib), left ventricular thrombus (post MI)

113
Q

What are less common thrombus causes of acute artery occlusion? (3)

A

Valvular heart disease, endocarditis, PFO

114
Q

What are noncardiac causes of acute artery occlusion? (4)

A

Atheroemboli, plaque rupture, hypercoagulability, trauma

115
Q

What are the symptoms of acute artery occlusion? (6)

A

Limb ischemia
pain/paresthesia
weakness
decreased peripheral pulses
cool skin
color changes distal to occlusion

116
Q

How is acute artery occlusion diagnosed?

A

Arteriography

117
Q

What is the treatment for acute artery occlusion?

A

Surgical embolectomy, anticoagulation, amputation (last resort)

118
Q

What is Subclavian Steal Syndrome?

A

Occluded SCA causing vertebral artery blood flow diversion from brain stem

119
Q

What are the symptoms of Subclavian Steal Syndrome? (5)

A

Syncope
vertigo
ataxia
hemiplegia
ipsilateral arm ischemia

120
Q

What are 3 risk factors for Subclavian Steal Syndrome?

A

Atherosclerosis
Takayasu arteritis
Aortic surgery

121
Q

What is the curative treatment for Subclavian Steal Syndrome?

A

SC endarterectomy

122
Q

What 2 assessment findings might be associated with subclavian steal syndrome?

A

Affected arm SBP ↓20mmHg
Bruit over SCA

123
Q

What is Raynaud’s Phenomenon?

A

Episodic vasospastic ischemia of the digits

124
Q

Who does Raynaud’s Phenomenon affect more, women or men?

A

affects women > men

125
Q

What are some symptoms of Raynaud’s Phenomenon?

A

Digital blanching or cyanosis w/cold exposure or SNS activation

126
Q

How is Raynaud’s Phenomenon diagnosed?

A

Based on history & physical

127
Q

What are 3 treatment options for Raynaud’s Phenomenon?

A

Protection from cold
CCBs
alpha-blockers

128
Q

In which cases is surgical sympathectomy considered for Raynaud’s Phenomenon?

A

For severe ischemia

129
Q

What are 3 common PVD processes that can occur during surgery?

A

Superficial thrombophlebitis
Deep vein thrombosis
Chronic venous insufficiency

130
Q

Why is DVT a major concern during surgery?

A

Can lead to PE, a leading cause of perioperative M & M

131
Q

What are the 3 major factors of Virchow’s Triad that predispose to venous thrombosis?

A

Venous stasis
Hypercoagulability
Disrupted vascular endothelium

132
Q

Superficial thombophlebitis and DVT occur in approximately 50% of what kind of surgery?

A

total hip replacement

133
Q

What are some risk factors for DVT? (5)

A

> age 40
surgery >1h
cancer
ortho surgeries on pelvis & LEs
abdominal surgery

134
Q

What 3 diagnostic tools are useful for detecting thrombosis?

A

Doppler U/S
Venography
Impedance plethysmography

135
Q

What prophylactic measures can be taken to prevent thrombosis?

A

SCD’s
SQ heparin 2-3x/day
Regional anesthesia (d/t early ambulation)

136
Q

What are some moderate-risk medical conditions for developing deep vein thrombosis?

A

postpartum period
MI
CHF

137
Q

What are some high-risk factors for developing deep vein thrombosis?

A

Hx thombosis, stroke
Extensive trauma
Major fractures
Knee or hip replacement

138
Q

What are the recommended steps to minimize deep vein thrombosis?

A

Compression stockings
Early ambulation
anticoagulants
IVC

139
Q

How can deep vein thrombosis be diagnosed?

A

Compression ultrasonography or impedance plethysmography

140
Q

What should be done if deep vein thrombosis is suspected but US is normal?

A

Repeat imaging on days 2 and 7

141
Q

When can deep vein thrombosis be ruled out?

A

If no abnormalities are found on US and normal repeat US

142
Q

Which anticoagulants are used for Deep Vein Thrombosis (DVT) treatment?

A

Warfarin + Heparin or LMWH

143
Q

What are the advantages of LMWH over unfractionated heparin?

A
  • Longer half-life
  • more predictable dose response
  • doesnt require serial aPTT
  • Less risk of bleeding
144
Q

What are the disadvantages of LMWH?

A
  • higher cost
  • no reversal agent
145
Q

What is the recommended INR range when Warfarin is used for DVT treatment?

A

INR between 2-3

146
Q

How long are PO anticoagulants typically continued after a DVT?

A

6 months or longer

147
Q

In what situations may an IVC filter be placed for DVT patients?

A

Recurrent PE or contraindication to anticoagulants

148
Q

What are the 2 main types of large-artery vasculitis?

A

Takayasu arteritis
Temporal (giant cell) arteritis

149
Q

What is the primary vessel affected in Kawasaki disease?

A

Coronary arteries

150
Q

What are examples of medium to small-artery vasculitis?

A

Thromboangiitis obliterans, Wegener granulomatosis, Polyarteritis nodosa

151
Q

What is temporal (giant cell) arteritis?

A

Inflammation of arteries of the head and neck

152
Q

What are the symptoms of temporal arteritis?

A

Unilateral: headache, scalp tenderness, jaw claudication

153
Q

Why is prompt initiation of corticosteroids indicated in temporal arteritis visual symptoms?

A

To prevent blindness

154
Q

How is temporal arteritis diagnosed?

A

Biopsy of temporal artery shows arteritis in 90% of patients

155
Q

What is Thromboangiitis Obliterans also known as?

A

Buerger Disease

156
Q

What is Thromboangiitis Obliterans?

A

autoimmune inflammatory vasculitis ⇒ small/medium vessel occlusion in extremities

157
Q

What triggers the autoimmune response in Buerger Disease?

A

Nicotine

158
Q

What is the most predisposing factor for Buerger Disease?

A

Tobacco use

159
Q

Who is Buerger Disease most prevalent in?

A

Men <45

160
Q

What are the 5 diagnostic criteria for Buerger Disease?

A
  • Hx smoking
  • onset before 50
  • infrapopliteal arterial occlusive disease
  • upper limb involvement
  • absence of risk factors for atherosclerosis
161
Q

How is the diagnosis of Buerger Disease confirmed?

A

Biopsy of vascular lesions

162
Q

What are the symptoms of Thromboangiitis Obliterans ‘Buerger Disease’?

A
  • forearm, calf, foot claudication
  • Ischemia of hands & feet
  • Ulceration and skin necrosis
  • Raynaud’s
163
Q

What is considered the most effective treatment for Thromboangiitis Obliterans ‘Buerger Disease’?

A

Smoking cessation

164
Q

What are the anesthesia implications for Thromboangiitis Obliterans ‘Buerger Disease’?

A

Meticulous positioning/padding
Avoid cold ⇒ Warm room
Prefer non-invasive BP
Conservative line placement

165
Q

What is Polyarteritis Nodosa?

A

Antineutrophyl cytoplasmic antibody (ANCA) negative vasculitis

166
Q

What are possible associations of Polyarteritis Nodosa?

A

Hepatitis B, Hepatitis C, Hairy Cell Leukemia

167
Q

What are some complications of Polyarteritis Nodosa?

A

Glomerulonephritis
myocardial ischemia
peripheral neuropathy
seizures

168
Q

What is the primary cause of death in Polyarteritis Nodosa?

A

Renal failure

169
Q

How is Polyarteritis Nodosa treated?

A

Steroids, cyclophosphamide, treating underlying cause

170
Q

What coexisting conditions should anesthesia consider in Polyarteritis Nodosa patients?

A

Renal disease, cardiac disease, hypertension

171
Q

What are 2 mild symptoms of lower extremity chronic venous disease?

A

Telangiectasias, varicose veins

172
Q

What are 3 severe symptoms of lower extremity chronic venous disease?

A

Edema, skin changes, ulceration

173
Q

What are some risk factors for lower extremity chronic venous disease?

A

Advanced age
family hx
pregnancy
obesity
smoking
prolonged standing

174
Q

What are the diagnostic criteria for Lower Extremity Chronic Venous Insufficiency?

A

Leg pain, heaviness, fatigue. Ultrasound showing venous reflux.

175
Q

What is the initial treatment for Lower Extremity Chronic Venous Insufficiency?

A

Leg elevation
exercise
weight loss
compression therapy
skin barriers/emollients
steroids
wound management.

176
Q

What are some conservative medical management options for Lower Extremity Chronic Venous Disease?

A

Diuretics
Aspirin
Antibiotics
Prostacyclin analogues
Zinc sulfate

177
Q

When can ablation be considered for Lower Extremity Chronic Venous Disease?

A

If medical management fails

178
Q

What are the methods of ablation for Chronic Venous Disease?

A

Thermal ablation w/laser, Radiofrequency ablation, Endovenous laser ablation, Sclerotherapy

179
Q

What are the indications for ablation in Chronic Venous Disease?

A

Venous hemorrhage, Thrombophlebitis, Symptomatic venous reflux

180
Q

What are the contraindications for ablation in Chronic Venous Disease?

A

Pregnancy, Thrombosis, PAD, Limited mobility, Congenital venous abnormalities

181
Q

What are some surgical interventions for Lower Extremity Chronic Venous Disease?

A

Saphenous vein inversion
High saphenous ligation
Ambulatory Phlebectomy
Transilluminated-powered phlebectomy
Venous ligation
Perforator ligation

182
Q

What is the leading cause of perioperative morbidity and mortality in noncardiac surgery?

A

Cardiac complications

183
Q

Which group of patients has a higher incidence of cardiac complications during surgery?

A

Patients undergoing vascular surgery

184
Q

In patients with peripheral arterial disease, what is their increased risk of cardiovascular ischemic events compared to those without?

A

3-5 times greater risk

185
Q

What luminal diameter percentage represents significant stenosis in the carotid artery based on studies?

A

70-75%
(1.5 mm or >70%)

186
Q

What can occur if collateral cerebral blood flow is inadequate in carotid artery stenosis?

A

TIAs and ischemic infarction

187
Q

What blood pressure abnormalities can be observed during and after carotid endarterectomy?

A

Hypertension and hypotension

188
Q

What is the typical cause of acute arterial occlusion?

A

Cardiogenic embolism

189
Q

What can cause cardiogenic embolism?

A

Thrombus in the left ventricle due to MI or dilated cardiomyopathy

190
Q

List some cardiac causes of systemic emboli.

A

Valvular heart disease, prosthetic heart valves, infective endocarditis, left atrial myxoma, Afib, atheroemboli

191
Q

What is Thromboangiitis obliterans?

A

An inflammatory vasculitis leading to occlusion of small and medium-sized arteries and veins in the extremities

192
Q

What prophylactic measures do patients at low risk for DVT require?

A

Early ambulation, compression stockings

193
Q

Which patients may have a higher risk of DVT?

A

> 40 y/o
surgery >1 hour
LE orthopedic
pelvic or abdominal surgery
Prolonged bedrest

194
Q

What is an improvement seen with endovascular repair of aortic lesions?

A

Significant perioperative mortality improvement

24 Physical & Health Assessment (33 decks)

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