Vascular Disease Ex 3 Flashcards
What is an aortic aneurysm?
When is surgery indicated?
Dilation of all 3 layers of artery leading to >50% inc in diameter.
Sx indicated at >5.5 cm diamer
Rupture associated w 75% mortality rate
Describe the 2 types of aneurysm (fusiform and sacular)?
What are the symptoms
- Fusiform: Uniform dilation along entire circumference of arterial wall
- Saccular: berry-shaped bulge to one side
s/s: Asymptomatic or pain d/t surrounding compression
Treatment for Aortic aneurysm?
Surgery indicated if >5.5 diameter, growth >10 mm a year, family history of dissection.
-medical managment to limit expansion, manage BP, cholesterol, stop smoking!
-endovascular stent repair > open surgery
What is aortic dissection?
What type of dissection requires emergency treatment?
-tear in intimal layer of vessel, causing blood to enter medial layer.
-Ascending dissection (standford A, debakey 1 &2) requires emergent surgical intervention! mortality >1-2% per hr, mortality 27-58%.
s/s severe sharp back pain
What is the most common procedures for Standard A dissection?
- ascending aorta & aortic valve replacement w/a composite graft
- replacement of the ascending aorta and resuspension of the aortic valve
standford A = ascending aorta
Aortic arch surgery requires bypass, hypothermia and a period of circulatory arrest
What deficits are common w replacement of aortic arch?
Neurological deficits :( ~3-18% pts
Selective antegrade cerebral perfusion decreases the morbidity and mortality risk
Standard B dissection affects what part of the aorta?
- aka debakey III.
Descending thoracic Aorta: acute, but uncomplicated type B aortic dissection w normal hemodynamics, no periaortic hematoma, and no branch vessel involvement. Can be treated with medical therapy :)
What is the medical therapy for descending thoracic aorta (type b)
- SBP arterial monitoring and UOP monitoring
- drugs to control BP and force of LV contraction (BB, Cardene, nitroprusside)
Rarely requires urgent surgery
Surgery is indicated for patients with type B dissection who have impending signs of rupture. What are the signs?
impending rupture: persistent pain, hypotension, left-sided hemothorax
other symptoms that call for surgery: ischemia of the legs, abdominal viscera, spinal cord, and/or renal failure
Has 29% in hospital mortality rate
Rish factors for aortic
dissections??
Inherited disorder risk factors??
HTN, aneurysms, fam hx, cocaine use, & inflammatory diseases
Marfans, Ehlers Danlos, Bicuspid Aortic Valve, non-syndrome familial hx
What are some causes of dissection?
-Causes of dissection: blunt trauma, cocaine, iatrogenic (c/b medical treatment)
-Iatrogenic causes related to: cardiac catheterization, aortic manipulation, cross-clamping & arterial incision
Dissection common in ____ and _____
men and preggo women in 3rd trimester
What are triad of symptoms in 1/2 cases of AA rupture?
Most aneurysms rupture into the ____
hypotension, back pain, pulsatile mass
left retroperitoneum
Euvolemic resuscitation may be deferred until rupture is surgically controled bc euvolemic resuscitation and the increase in BP without control of bleeding may lead to loss of ___, ____ , ____, ___
retroperitoneal tamponade, further bleeding, hypotension, and death
Unstable patients w suspected AAA require operation without preop testing or volume rescusitation!
What are 4 causes of mortality of thoracic aorta surgery?
Ischemic heart dx may require ____ before ____
MI, respiratory failure, renal failure and stroke
Ischemic heart diagnosis may require intervention prior to surgery
Severe reduction in ____ or ____ may preclude a pt from AAA resection.
What are 2 predictors of postaortic surgery respiratory failure?
FEV1 or renal failure!
Smoking and COPD
PFT and ABG to define risk
What interventions to take for renal protection?
What to get if pt has hx of stroke/tia
preop hydration, avoid hypovolemia/ hypotension and low CO, and avoid nephrotoxic drugs
Carotid US and angiogram of braciocephalic and intracranial arteries
carotid endarectomy workup before elective surgery if severe stenosis!
Ichemia to anterior spinal artery syndrome leads to what 3 things?
Anterior spinal artery responsible for anterior 2/3 of spinal cord
- loss motor function below the infarct
- diminished pain and temperature sensation below the infarct
- antonomic dysfunction leading to hypotension and loss of bowel & bladder function
Why is anterior spinal artery the most common form of spinal cord ischemia?
Bc it has minimal collateral perfusion
Posterior spinal cord is perfused by 2 posterior spinal arteries! So it has better collateral circulation
What are 4 common causes of anterior spinal artery syndrome?
Aortic aneurysms, aortic dissection, atherosclerosis, trauma
TIA symptoms resolve within ____.
What is a prominent predictor of CVA?
24 hours
Carotid disease
Carotid disease testing
Angiography can diagnose what ?
CT/ MRI may identify ___ and ____
- Angiography- can diagnose vascular occlusion
- CT & MRI- less invasive, may also identify aneurysms and AVMs
Transcranial doppler US may give indirect evidence of:
Carotid auscultation may help identify
Carotid U/S may quantify degree of
vascular occlusion w real time bedside monitoring
bruits
carotid stenosis
What is the treatment for CVA?
IR: thrombolysis (tpa within 4.5 hr) thrombectomy
Carotid endarterectomy (for severe >70% blockage)
Carotid stenting *has major risk for microembolization (CVA)
What is the medical treatment for CVA? (5)
AHA recommends TPA within
-antiplatelet tx, smoking cessation, BP control, cholesterol control, diet and phyical activity
4.5 hr
During carotid endarecotmy,
maintain _____ through stenotic vessels (especially during cross clamping)
Maintain collateral blood flow!
Extreme head rotation/flexion during CEA may ____ contralateral artery flow.
Cerebral oximetry devices may be useful in determining ___ ____
compress
cerebral perfusion
Cerebral O2 consumption is affected by: (2)
Cerebral oxygenation affected by: (5)
temperature and anesthesia!
Oxygenation affected by MAP, CO, SaO2, HGB, PaCO2
What is peripheral artery disease defined by?
Ankle branchial index <0.9
ABI= ratio of SBP at ankle/ SBP at brachial artery
PAD
Common cause of acute occlusion?
Common cause of chronic hypo perfusion?
acute: embolism
Chronic: atherosclerosis
atherosclerosis is systemic! they have 3-5x risk of and CVA
How is PAD diagnosed (4) ?
-doppler u/s: provides pulse volume waveform, identifies arterial stenosis
-duplex u/s: identifies areas of plaque & calcification
-transcutanous oximetry: assesses severity of tissue ischemia
-MRI w contast: guides endo intervention & surgical bypass
S/S of PAD
- Intermittent claudication
- Resting extremity pain
- Decreased pulses
- Subcutaneous atrophy
- Hair loss
- Coolness
- Cyanosis
Relief w hanging extremities over side of the bed to increase hydrostatic pressure
What is the treatment for PAD?
revascularization indicated w disabling ischemia.
Surgical reconstruction artery bypass procedure
endovascular repair: transluminal angioplasty or stent placement
What are s/s of acute artery occlusion?
What are 2 common causes?
s/s limb ischemia, pain/parethesia, weakness, diminshed pulses, cool skin, color changes distal to occlusion
L atrial thrombus from a fib and LV thrombus from dilatated cardiomyopathy
How is acute attery occlusion diagnosed and what is the treatment?
diagnosed with arteriogram.
Treatment: surgical embolectomy, anticoagulation and amputation (last resort)
What is subclavian steal syndrome?
What is the treatment?
SC steal: occluded subclavian artery, proximal to vertebral artery. Vertebral blood flow is diverted away from brain stem.
Subclavian endarterectomy
What are s/s for subclavian steal syndrome?
s/s syncope, vertigo, ataxia, hemiplagia, ipsilateral arm ischemia, affected arm
SBP 20 mmHG lower
bruit over SCA
Risk factors: athersclerosis, takayasu arteritis, aortic sx
Raynaud’s phenomenon may appear with ___ syndrome
CREST
PVD
What is virchows triad?
3 major factors that predispose to venous thrombosis
Venous stasis, Hypercoagulability, and Disrupted vascular endothelium
What are 3 common PVD processes that occur during surgery?
- Superficial thrombophlebitis
- Deep vein thrombosis
- Chronic venous insufficiency
DVT treatment: AC w/ warfarin + heparin or LMWH
What are advantages for LMWH over unfractionated heparin?
What are 2 disadvantages?
longer HL & more predictable dose response
doesn’t require serial assessment of activated partial thromboplastin time
Less risk of bleeding
higher cost and lack of reversal agent
DVT treatment
Warfarin is initiated during ____ treatment and adjusted to achieve what levels of INR?
When is heparin d/c?
How long are PO AC continued for
heparin, INR between 2-3
Heparin d/c when warfarin achieves therapeutic effect
6 months or longer
IVC filter may be required if AC contraindication! or recurrent PE!
What is systemic vasculitis?
- Diverse group of vascular inflammatory diseases with characteristics that are often grouped by the size of the vessels at the primary site of the abnormality
Large artery vasculitis includes:
Takayasu arteritis
* Temporal (or giant cell) arteritis
Systemic vasculitis can be a feature of connective tissue diseases such as what 2 disorders?
Lupus and rheumatoid arthritis
Medium artery vasculitis includes:
- Kawasaki disease, which is most prominently the coronary arteries
Medium to small artery vasculitis includes: (3)
- thromboangiitis obliterans
- Wegener granulomatosis
- polyarteritis nodosa
Temporal arteritis is inflammation of which arteries (giant cell)
What are the s/s (3)
inflamamtion of arteries of the head and the neck.
s/s unilateral; headache, scalp tenderness, jaw claudication
Temporal (giant cell) arteritis
Opthalmic arterial branches may lead to ischemic ____ ______ and unilateral _____
ischemic optic neuritis and unilateral blindness
What is the treatment of temporal arteritis?
How is it diagnosed
Treatment: corticosteroid initiation to prevent blindness!
Dx: biopsy of temporal artery
What is thromboangiitis obliterans burger disease?
Tx?
- Inflammatory vasculitis leading to small & medium vessel occlusions in the extremities
- Autoammune response to nicotine! MEN 45>
surgical revascularizaiton, no effective pharm tx, stop smoking!!
Thromboangiitis Obliterans
What are 5 diagnostic criteria for buerger disease
What confirms diagnosis?
- h/o smoking
- onset before 50
- infrapopliteal arterial occlusive dz
- upper limb involvement
- Absence of risks factors for atherosclerosis (outside of tobacco)
biopsy of vascular lesions
S/S of thromboangiitis obliterians disease
S/S
* forearm, calf, foot claudication
* Ischemia of hands & feet
* Ulceration and skin necrosis
* Raynaud’s is commonly seen
Thromboangiitis Obliterans
What are 3 anesthesia implications for burger disease?
- Meticulous positioning/padding
- Avoid cold; Warm the room and use warming devices
- Prefer non-invasive BP and conservative line placement
What is polyarteritis nodosa?
What diseases is it associated with ?
Which arteries are involved
- Antineutrophyl cytoplasmic antibody (ANCA) negative vasculitis
- May be assoc w/ Hep B, Hep C, or Hairy Cell Leukemia
Medium and small arteries!
In polyarteritis nodosa, inflammation results in what 4 complications?
What is the treatment?
- Inflammation results in glomerulonephritis, myocardial ischemia, peripheral neuropathy and seizures
Tx: steroids, cyclosphamide, treat cause (Cancer)
anethesia: consider renal disease, cardiac disease and HTN, steroids!
Diagnostic criteria for lower extremity chornic disease includes:
Sx of leg pain, heaviness, fatigue
* Confirmed by ultrasound showing venous reflux
* Retrograde blood flow > 0.5 seconds
Initially, therapy for lower extremity chornic disease is conservative!
What are 4 types of ablation treatment for lower extremity chronic venous disease if medical managment fails?
thermal ablation w laser, radiofrequency ablation, endovenous lase ablation and sclerotherapy
If medical therapy fails, ablation may be performed
What are the indications for ablation therapy for chronic venous diasease
Indications:
* Thrombophlebitis
* Symptomatic venous reflux
* Venous hemorrhage
What are some contraindications for chronic venous disease ablation? (5)
Pregnancy
Thrombosis
PAD
Limited mobility
Congenital venous abnormalities
Surgical intervention for lower extremity chronic venous disease is usually ___ ____.
What are 6 possible procedures?
last resort!
- Saphenous vein inversion
- High saphenous ligation
- Ambulatory Phlebectomy
- Transilluminated-powered phlebectomy
- Venous ligation
- Perforator ligation
What is the leading cause of mortality in pt undergoing non cardiac surgery?
Data from transcranial doppler and carotid duplex us suggest that carotic stenosis w. 1.5 mm diameter represents _____. What may occur?
cardiac complications
significant stenosis! TIA and ischemic infarctions may occur if collateral flow is not adequate
What 2 complications are oberved during and after carotid endarectomy?
Acute arterial occlusion is typically caysed by ___ _____
hypotension and hypertension.
cardiogenic embolism *arising from LV due to MI or dilated cardiomyopathy
The risk of DVT is higher in patients over 40 y/o undergoing what types of surgeries?
Endovascular repair of aortic lesions is a new technique with improvements in ___ _____
surgery >1 hour, especially LE orthopedic, pelvic or abdominal surgery, and surgeries that require a prolonged bed rest or limited mobility
Perioperative mortality. They are less invasive :)
What’s the best diagnostic tool in case you suspect a aneurysm dissection
Doppler echo is safest measure of diagnosing aneurysm
