Vascular disease (exam 4) Flashcards
1
Q
What are the three main arterial pathologies?
A
Aneurysms, dissections, occlusions
2
Q
Which arteries are more likely to be affected by aneurysms and dissections?
A
Aorta and its branches
3
Q
Which arteries are more likely to be affected by occlusions?
A
Peripheral arteries
4
Q
What defines an aortic aneurysm?
A
Dilation of all 3 layers of artery, leading to a >50% increase in diameter
5
Q
What are common symptoms of an aortic aneurysm?
A
Asymptomatic or pain due to surrounding compression
6
Q
When is surgery indicated for an aortic aneurysm?
A
When diameter is >5.5 cm
7
Q
What is the mortality rate associated with aortic aneurysm rupture?
A
75%
8
Q
What are the two types of aortic aneurysms?
A
- Saccular: outpouching bulge to one side
- Fusiform: Uniform circumferential dilation
9
Q
What diagnostic tools are used for aortic aneurysms?
A
- CT
- MRI
- CXR
- Angiogram
- Echocardiogram
10
Q
What is the fastest/safest measure for obtaining a diagnosis of an aortic dissection?
A
Doppler echocardiogram
11
Q
What is an aortic dissection?
A
Tear in intimal layer of the vessel, causing blood to enter the medial layer
12
Q
What type of dissection requires emergent surgical intervention?
A
Ascending dissection
13
Q
What is the overall mortality rate for aortic dissections?
A
27-58%
*mortality increases by 1-2% per hour
14
Q
What is the classification system for aortic dissections?
A
Stanford Class A, B and DeBakey Class 1, 2, 3
15
Q
Which Stanford and Debakey class dissection involves the ascending aorta?
A
Stanford Class A, Debakey 1&2
16
Q
What surgical procedures are commonly performed for Stanford A dissection?
A
- Ascending aorta & aortic valve replacement with a composite graft
- Ascending aorta replacement with resuspension of the aortic valve
17
Q
What is the treatment for uncomplicated Stanford B dissections?
A
Medical management
18
Q
What medical therapy is indicated for type B dissection?
A
- Intraarterial monitoring of SBP and UOP
- Drugs to control BP and force of LV contraction (BBs, Cardene, SNP)
19
Q
What are the risk factors for aortic dissections?
A
- HTN
- Atherosclerosis
- Aneurysms
- Family history
- Cocaine use
- Inflammatory diseases
20
Q
What are the common causes of Anterior Spinal Artery Syndrome?
A
- Aortic aneurysms
- Aortic dissection
- Atherosclerosis
- Trauma
21
Q
What is the primary cause of ischemia in Anterior Spinal Artery Syndrome?
A
Lack of blood flow to the anterior spinal artery
22
Q
What are the symptoms of Anterior Spinal Artery Syndrome?
A
- Loss of motor function below the infarct
- Diminished pain and temperature sensation below the infarct
- Autonomic dysfunction
23
Q
What is a CVA?
A
Cerebral Vascular Accident, can be ischemic or hemorrhagic
24
Q
What is the first leading cause of disability in the US?
A
CVA
Ischemic (87%), hemorrhagic (13%, most deadly)
25
What is a TIA?
Temporary, self-limited ischemia with symptoms resolving within 24 hours
26
What is the recommended treatment for CVA according to the American Heart Association?
TPA within 4.5 hours of onset
27
What is Carotid Endarterectomy (CEA)?
Surgical treatment for severe carotid stenosis
28
What are the components of Virchow's Triad that predispose to venous thrombosis?
* Venous stasis
* Disrupted vascular endothelium
* Hypercoagulability
29
What is the definition of Peripheral Artery Disease?
Compromised blood flow to the extremities defined by an ankle-brachial index (ABI) <0.9
30
What are the signs and symptoms of Peripheral Artery Disease (7)?
* Intermittent claudication
* Resting extremity pain
* Weak pulses
* Subcutaneous atrophy
* Hair loss
* Coolness
* Cyanosis
**Relief w/hanging LE over side of bed (increased hydrostatic pressure)
31
What is the treatment for acute peripheral artery occlusion?
* Anticoagulation
* Surgical embolectomy
* Amputation (last resort)
32
What is Subclavian Steal Syndrome?
Occluded SCA proximal to vertebral artery causing vertebral artery flow to divert away from brainstem
33
What are the symptoms of Subclavian Steal Syndrome?
* Syncope
* Vertigo
* Ataxia
* Hemiplegia
* Ipsilateral arm ischemia (worse with activity)
34
What is Raynaud's Phenomenon?
Episodic vasospastic ischemia of the digits
35
What are common risk factors for DVT?
* Age >40
* Surgery >1 hour
* Cancer
* Orthopedic surgeries on pelvis & LEs
* Abdominal surgery
36
What is the most significant indicator of post-aortic surgery renal failure?
Preoperative renal dysfunction
37
What is the purpose of cerebral oximetry devices?
To gauge and trend cerebral perfusion
38
What does the ankle-brachial index (ABI) measure?
The ratio of SBP at the ankle to SBP at the brachial artery
39
What is plethysmography?
A method used to measure changes in volume within an organ or whole body
40
What are some prophylactic measures for DVT?
Compression stockings, SCD’s, SQ heparin 2-3x/day
**Regional anesthesia can greatly decrease the risk of DVT d/t earlier post-op ambulation
41
How can regional anesthesia affect DVT risk?
It can greatly reduce risk due to earlier postoperative ambulation
42
What is the primary treatment for DVT?
Anticoagulation
43
What combination of medications is commonly used in DVT treatment?
Warfarin + Heparin or LMWH
44
What are the advantages of LMWH over unfractionated heparin?
* Longer half-life
* More predictable dose response
* Does not require serial assessment of aPTT
* Less risk of bleeding
45
What are the disadvantages of LMWH?
* Higher cost
* Lack of reversal agent
46
What is the INR range that Warfarin is adjusted to during treatment?
2-3
47
When is heparin discontinued during DVT treatment?
When Warfarin achieves therapeutic effect
48
How long are oral anticoagulants continued after DVT treatment?
6 months or longer
49
When might an IVC filter be indicated?
With recurrent PE or contraindication to anticoagulants
50
What is systemic vasculitis?
A group of vascular inflammatory diseases categorized by the size of the vessels at the primary site of the abnormality
51
What conditions are included in large-artery vasculitis?
* Takayasu arteritis
* Temporal (or giant cell) arteritis
52
What condition is classified under medium-artery vasculitis?
Kawasaki disease (usually affects the coronary arteries)
53
What conditions fall under medium to small-artery vasculitis?
* Thromboangiitis obliterans
* Wegener granulomatosis
* Polyarteritis nodosa
54
What are the symptoms of Temporal (Giant Cell) Arteritis?
* Unilateral headache
* Scalp tenderness
* Jaw claudication
55
What is the diagnostic method for Temporal Arteritis?
Biopsy of temporal artery shows arteritis in 90% of patients
56
What treatment is indicated for visual symptoms in Temporal Arteritis?
Corticosteroids
57
What is Thromboangiitis Obliterans also known as?
Buerger Disease
58
What triggers Thromboangiitis Obliterans?
Autoimmune response triggered by nicotine
59
What are the 5 diagnostic criteria for Thromboangiitis Obliterans?
* History of smoking
* Onset before 50 (usually <45)
* Infrapopliteal arterial occlusive disease
* Upper limb involvement
* Absence of risk factors for atherosclerosis (outside of tobacco)
60
What are the symptoms of Thromboangiitis Obliterans?
* Forearm, calf, foot claudication
* Ischemia of hands & feet
* Ulceration and skin necrosis
* Raynaud's phenomenon
61
What is the most effective treatment for Thromboangiitis Obliterans?
Smoking cessation
62
What are the anesthesia implications for patients with Thromboangiitis Obliterans?
* Meticulous positioning/padding
* Avoid cold; warm the room and use warming devices
* Prefer non-invasive BP and conservative line placement
63
What is Polyarteritis Nodosa?
Vasculitis of the small and medium vessels
64
What complications can arise from Polyarteritis Nodosa?
* Glomerulonephritis
* Myocardial ischemia
* Peripheral neuropathy
* Seizures
65
What is the primary cause of death in Polyarteritis Nodosa?
Renal failure
66
What treatments are used for Polyarteritis Nodosa?
* Steroids
* Cyclophosphamide
* Treating underlying cause (e.g., cancer)
67
What are the symptoms of Lower Extremity Chronic Venous Disease?
MILD
* Telangiectasias
* Varicose veins
SEVERE
* Edema
* Skin changes
* Ulceration
68
What risk factors are associated with Lower Extremity Chronic Venous Disease?
* Advanced age
* Family history
* Pregnancy
* Ligamentous laxity
* Previous venous thrombosis
* LE injuries
* Prolonged standing
* Obesity
* Smoking
* Sedentary lifestyle
* High estrogen levels
69
What are the diagnostic criteria for Lower Extremity Chronic Venous Insufficiency?
Symptoms of leg pain, heaviness, fatigue confirmed by ultrasound showing venous reflux
70
What are the initial treatments for Lower Extremity Chronic Venous Insufficiency?
* Leg elevation
* Exercise
* Weight loss
* Compression therapy
* Skin barriers/emollients
* Steroids
* Wound management
71
What conservative medical management options are available for Lower Extremity Chronic Venous Disease?
* Diuretics
* Aspirin
* Antibiotics
* Prostacyclin analogues
* Zinc sulphate
**If management fails, ablation may be performed
72
What surgical interventions may be performed for Lower Extremity Chronic Venous Disease?
* Saphenous vein inversion
* High saphenous ligation
* Ambulatory phlebectomy
* Transilluminated-powered phlebectomy
* Venous ligation
* Perforator ligation
73
What are the (6) treatment options for an aortic aneurysm?
1. Medical management to ↓expansion rate
2. Manage BP, Cholesterol, stop smoking
3. Avoid strenuous exercise, stimulants, stress
4. Regular monitoring for progression
5. Surgery indicated if >5.5 cm, growth >10mm/yr, family h/o dissection
6. Endovascular stent repair has become a mainstay over open surgery w/graft
a. AAA stent repair, CV surgeon on standby
b. Done under fluroscopy
74
How are stable and unstable aortic dissections diagnosed?
1. stable: CXR, CT, MRI, angiogram
2. unstable: echocardiogram
75
What is the primary symptom of an aortic dissection?
Severe sharp pain in posterior chest or back
76
What is a major complication associated with aortic arch replacement? Seen in 3-18% of pts
Neurological deficit
77
T/F: if the dissection involves the aortic arch, it can be medically managed
False: surgical resection is indicated
*Surgery requires cardiopulmonary bypass, profound hypothermia, and a period of circulatory arrest
78
At what body temp and duration can most pts tolerate circulatory arrest?
15-18* C for 30-40 minutes
79
What are the s&s of a type B dissection that require surgery?
1. signs of impending rupture (pain, hypotension, left-sided hemothorax)
2. compromised perfusion to the lower body
80
What are general causes of an aortic dissection?
1. blunt trauma
2. cocaine
3. Iatrogenic (cardiac cath, aortic manipulation, cross-clamping, arterial incision)
81
T/F: aortic dissections are more common in men and pregnant women in the 3rd trimester.
True!
82
What is the triad of symptoms seen with an aortic aneurysm?
1. Hypotension
2. Back pain
3. A pulsatile abdominal mass
83
Where do most aortic aneurysms rupture?
The left retroperitoneum
84
T/F: if retroperitoneal tamonade occurs, volume resuscitation may be delayed until the rupture is surgically controlled.
True!
85
What are the (4) primary causes of mortality r/t surgeries of the thoracic aorta?
1. MI
2. respiratory failure
3. renal failure
4. stroke
86
T/F: high FEV1 or renal failure may preclude a pt from aortic resection
False:a LOW FEV1 or renal failure will preclude a pt from surgery
87
T/F: preop renal dysfunction is the most significant indicator of post-aortic surgery renal failure
True!
**Preop hydration, avoid hypovolemia, HoTN & low cardiac output
88
What is anterior spinal artery syndrome (ASA)?
Caused by lack of blood flow to the anterior spinal artery
89
How much of the spinal cord does the ASA perfuse?
2/3 of the anterior spinal cord
90
What does ischemia of the ASA lead to (3)?
1. loss of motor function below the infarct
2. diminished pain and temperature sensation below the infarct
3. autonomic dysfunction, leading to HoTN and bowel & bladder dysfunction
91
Where does carotid stenosis commonly occur?
at the carotid bifurcation due to turbulent blood flow at the branch-point
92
Carotid _______ can identify bruits
Auscultation
93
Carotid _____ can quantify the degree of carotid stenosis
Ultrasound
94
_____ can dx vascular occlusion
Angiography
95
_____ may give evidence of vascular occlusion with real-time monitoring
Transcranial doppler ultrasound
96
A carotid endarterectomy (CEA) is indicated when the carotid lumen diameter reaches _____ or _____ blockage
1.5mm or >70% blockage
97
T/F: In a pt with severe carotid disease + severe coronary artery disease, the least compromised area should take priority with surgery
False: the most compromised area should take priority
98
Considerations during CEA preop evaluation (6)
1. neurological eval/baseline
2. cardiac eval
3. establish acceptable BP range to optimize CPP
4. maintain collateral blood flow through stenotic vessels
5. avoid extreme head rotation/flexion/extension
6. use cerebral oximetry devices
99
What (5) things affect cerebral oxygenation?
1. MAP
2. CO
3. SaO2
4. Hgb
5. PaCO2
100
What (2) things affect cerebral oxygen consumption?
1. Temperature
2. Depth of anesthesia
101
An ankle-brachial index (ABI) of _____ indicates PAD
<0.9
*SBP @ ankle compared to SBP @ brachial artery
102
Chronic hypoperfusion to the extremities is usually due to _____
arterosclerosis
103
Acute occlusions/hypoperfusion is usually due to _____
embolism
104
Pts with PAD have a _____ increased risk of MI & CVA
3-5x
105
What are the risk factors for PAD (7)?
1. advanced age
2. family hx
3. smoking
4. DM
5. HTN
6. obesity
7. high cholesterol
106
What are the (2) treatments indicated w/disabling claudication or ischemia?
1. surgical reconstruction: arterial bypass procedure
2. endovascular repair: angioplasty or stent placement
107
Common causes (2) of acute peripheral artery occlusion
1. LEFT atrial thrombus (afib)
2. LEFT ventricular thrombus (cardiomyopathy after MI)
108
How is acute peripheral artery occlusion diagnosed?
Arteriogram
109
With subclavian steal syndrome, the affected arm SBP may be ______ lower
20 mmHg
110
Risk factors for subclavian steal syndrome (3)
1. atherosclerosis
2. h/o aortic surgery
3. Takayasu arteritis
111
T/F: Reynaud's phenomenon affects men greater than women
False: women>men
112
Treatment for Reynaud's phenomenon (4)
1. protection from cold
2. CCBs
3. alpha-blockers
4. surgical sympathectomy (for severe ischemia)
113
(3) common PVD processes that occur during surgery
1. superficial thrombophlebitis
2. deep vein thrombosis
3. chronic venous insufficiency
114
What is the diagnostic criteria for temporal (giant cell) arteritis?
Biopsy of temporal artery
115
T/F: There is no effective pharmacological treatment for thromboangiitis obliterans (Buerger disease)
True!
116
What are the anesthesia implications for polyarteritis nodosa (3)?
1. consider coexisting renal disease
2. cardiac disease
3. hypertension
