Vascular Disease - Exam 4 Flashcards
1
Q
What are the 3 main pathologies of vascular disease?
What is more likely to be affected by each?
A
aneurysms, dissections: aorta & it’s branches
occlusions: peripheral arteries
2
Q
What is an aortic aneurysm?
Symptoms may be due to what?
A
Dilation of all 3 layers of artery, leading to a >50% increase in diameter
Compression of surrounding structures
3
Q
Aortic aneurysms are initially treated _____, but surgery is indicated if >___cm diameter
A
Medically
5.5 cm
4
Q
Aneurysm rupture is associated with what mortality rate?
A
75%
5
Q
What are the 2 types of aortic aneurysms? What do they mean?
A
Saccular: outpouching bulge to one side
Fusiform: Uniform circumferential dilation
6
Q
Symptoms of aortic aneurysm
A
Asymptomatic or pain d/t surrounding compression
7
Q
Diagnostic tools for aortic aneurysm
A
CT, MRI, CXR, Angiogram, Echocardiogram
8
Q
What is the fastest/safest measure of obtaining a diagnosis of aneurysm?
A
Doppler echo
9
Q
Aortic aneurysm treatment
A
- 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
10
Q
What does dissection mean?
A
Tear in intimal layer of the vessel, causingblood to enter the medial layer
11
Q
What is a AAA dissection?
A
Catastrophic, requiresemergent surgical intervention
- Mortality increases by 1-2% per hr
12
Q
What is the overall mortality of AAA dissection?
A
27%-58%
13
Q
Symptoms of AAA dissection
A
Severe sharp pain in posterior chest or back
14
Q
Diagnosis of aortic dissection
A
Stable= CXR, CT, MRI, Angiogram
Unstable=Echocardiogram
15
Q
What are the aortic aneurysm-dissection classifications?
A
Stanford Class A, B
DeBakey Class 1,2,3
16
Q
Second picture for aortic aneurysm classifications
A
17
Q
Describe Stanford A dissection
A
Ascending aorta involved
Should be considered candidates for surgery
18
Q
The most commonly performed procedures for Stanford A dissection:
A
ascending aorta & aortic valve replacement w/a composite graft
ascending aorta replacement with resuspension of the aortic valve
19
Q
With Stanford A, if ____ is involved, surgical resection is indicated
A
Aortic arch
20
Q
Aortic arch surgery requires:
A
Cardiopulmonary bypass, profound hypothermia, and aperiod of circulatoryarrest
- Circulatory arrest at a bodytemp 15-18°C for 30-40 minutes can be tolerated by mostpts
21
Q
What is a major complication associated with aortic arch replacement?
What % of pts experience this?
A
Neurologic deficit
3%-18%
22
Q
What are the most serious types of aortic aneurysm dissection and always requires emergent surgery?
A
- Stanford A, Debakey 1 & 2
23
Q
What is a Stanford B dissection?
A
Descending thoracic Aorta: An uncomplicated type B dissection with normal hemodynamics, no hematoma, and no branch vessel involvement can be treated medically
24
Q
Medically therapy for Stanford B dissection include?
A
- intraarterial monitoring of SBP and UOP
- drugs to control BP and the force of LV contraction (BBs, Cardene, SNP)
25
Surgery is indicated for type B dissection with signs of what?
impending rupture (persistent pain, hypotension, left-sided hemothorax) or compromised perfusion to the lower body
26
Ascending arch dissections require _____, while descending arch dissections are rarely treated with ____
Emergent surgery
Urgent surgery
27
Descending arch dissections are often admitted for _____.
Symptoms for impending rupture include:
BP control (SA BBs, Aline)
Posterior, hypotension, hemothorax (requires surgery)
28
Risk factors of aortic dissection
HTN, atherosclerosis, aneurysms, fam hx, cocaine use, & inflammatory diseases
29
What are inherited disorders that could cause aortic dissection?
Marfans, Ehlers Danlos, Bicuspid Aortic Valve
30
Causes of aortic. dissection
What are the iatrogenic causes?
blunt trauma, cocaine, iatrogenic (c/b medical treatment)
Iatrogenic causes: cardiac catheterization, aortic manipulation, cross-clamping, arterial incision
31
Dissections are more common in what 2 pt populations?
Men
Pregnant women in 3rd trimester
32
Comparison between aortic aneurysm and dissection picture
33
What is the triad of symptoms seen in 1/2 cases for aortic aneurysm rupture?
Hypotension
Back pain
A pulsatile abdominal mass
34
Most abdominal aortic aneurysms rupture into the _____
Left retroperitoneum
35
If retroperitoneal tamponade occurs, _____ _____ be delayed until the rupture is surgically controlled, to maintain a lower BP and reduce risk of further bleeding, hypotension, and death
Volume resuscitation
36
4 primary causes of mortality r/t surgeries of thoracic aorta
MI
Respiratory failure
Renal failure
Stroke
37
____ or ___ may preclude a pt from aortic resection
Low FEV1
Renal failure
38
What are predictors of post aortic surgery respiratory failure?
Smoking/COPD
- consider bronchodilators, abx, CPT
39
What is the most significant indictor of post-aortic surgery renal failure?
Preop renal dysfunction
40
For severe carotid stenosis, workup the pt for ____ before elective surgery
CEA
41
What is anterior spinal artery (ASA) syndrome?
The anterior spinal artery perfuses the anterior 2/3 of the spinal cord
- caused by lack of blood flow to the anterior spinal artery
42
Ischemia caused by ASA syndrome leads to what?
- loss motor function below the infarct
- diminished pain and temperature sensation below the infarct
- antonomic dysfunction, leading to hypotension and bowel & bladder dysfunction
43
_____ is the most common form of spinal cord ischemia. Why?
ASA syndrome
- the ASA has minimal collateral perfusion; The posterior spinal cord is perfused by two posterior spinal arteries, providing better collateral circulation
44
Common causes of ASA syndrome
Aortic aneurysms, aortic dissection, atherosclerosis, trauma
45
CVAs are 87% ______ or 13% _____
Ischemic
Hemorrhagic
46
What is a prominent predictor of CVA?
Carotid diagnosis
47
What is the 1st leading cause of disability in the US?
CVA
48
What is a TIA?
Symptoms usually resolve within ___ hr
temporary, self-limited ischemia
24 hr
49
Risk factors of CVA picture
50
Carotid diagnostic testing includes?
What can each test indicate?
Angiography: can dx vascular occlusion
CT/MRI: can identify aneurysms/AVM
Transcranial doppler US: can give evidence of vascular occlusions
Carotid auscultation: can identify bruits
Carotid US: can quantify degree of carotid stenosis
51
Carotid stenosis commonly occurs at the ____, due to what?
Carotid bifurcation
Turbulent blood flow at the branch-point
52
Workup for carotid stenosis includes evaluation for sources of emboli such as?
A-fib, heart failure, valvular vegetation
53
American heart association recommends TPA within ____hr of onset for CVA
4.5
54
What are other treatments of CVA? (this card is long, super sorry)
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
55
What is other ongoing medical therapy for CVA?
Antiplatelet tx
Smoking cessation
BP control
Cholesterol control
Diet & Physical activity
56
What is a major cause of periop mortality in CEA?
MI
57
What is the CPP equation?
CPP=MAP-ICP
58
What is the "clinical dilemma" in CEA preop eval?
severe carotid dz + severe coronary artery dz
- Must stage cardiac revascularization and CEA
- Most compromised area should take priority
59
Cerebral oxygenation is affected by:
MAP
COP
Sa02
HGB
PaC02
60
Cerebral O2 consumption is affected by:
Temperature
Depth Anesthesia
61
What is PAD?
peripheral artery disease
- Compromised blood flow to the extremities
- Defined by an ankle-brachial index (ABI) <0.9
62
63
What is ABI?
Ankle-brachial index
- ratio of SBP @ ankle : SBP @ brachial artery
64
In PAD, chronic hypo-perfusion is typically due to ___
Atherosclerosis
65
In PAD, acute occlusions are typically due to ____
Embolism
66
Risk factors of PAD
Advanced age
Family hx
Smoking
DM
HTN
Obesity
↑Cholesterol
67
S/S of PAD
Intermittent claudication
Resting extremity pain
Weak pulses
Subcutaneous atrophy
Hair loss
Coolness
Cyanosis
*Relief w/hanging LE over side of bed (↑hydrostatic pressure)
68
Diagnostics of PAD
What does each identify?
- 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
69
Medical tx of PAD
exercise, controlling BP, cholesterol, and glucose
70
Interventions for PAD
revascularization indicated w/disabling claudication or ischemia
- Surgical reconstruction- arterial bypass procedure
- Endovascular repair- angioplasty or stent placement
71
Common causes of acute peripheral artery occlusion
Cardiogenic embolism
- Left atrial thrombus d/t Afib
- Left ventricular thrombus d/t cardiomyopathy after MI
72
Symptoms of acute peripheral artery occlusion
limb ischemia, pain/paresthesia, weakness, ↓peripheral pulses, cool skin, color changes distal to occlusion
73
Diagnostics and treatment of acute peripheral artery occlusion
Arteriogram
Anticoagulation, surgical embolectomy, amputation (last resort)
74
What is subclavian steal syndrome?
occluded SCA, proximal to vertebral artery
- vertebral artery flow diverts away from brainstem
75
What are symptoms of SC steal syndrome?
Syncope, vertigo, ataxia, hemiplegia, ipsilateral arm ischemia
- Effected arm SBP may be ̴20mmhg lower
- Bruit over SCA
76
Risk factors and treatment of SC steal syndrome
atherosclerosis, h/o aortic surgery, Takayasu Arteritis
SC endarterectomy
77
What is Raynaud's?
Episodic vasospastic ischemia of the digits
Effects women > men
Primary or secondary causes
78
Symptoms and diagnosis of Raynaud's
digital blanching or cyanosis w/cold exposure or SNS activation
based on history & physical
79
Treatment of Raynaud's
protection from cold, CCBs, alpha-blockers
- Surgical sympathectomy for severe ischemia
80
Common PVD processes that occur in surgery
Superficial thrombophlebitis
Deep vein thrombosis
Chronic venous insufficiency
81
What is Virchow's triad?
Predispose to venous thrombosis
- Venous stasis
- Disrupted vascular endothelium
- Hypercoagulability
82
Risk factors for PVD chart
83
_____ and _____ are common during surgery
Superficial Thrombophlebitis & DVT
84
DVT is associated with ____ and ____
Risk factors include:
extremity pain and swelling
85
Risk factors of DVT
>age 40, surgery >1h, cancer, ortho surgeries on pelvis & LEs, abdominal surgery
86
Diagnosis of DVT
Doppler U/S, venography, impedance plethysmography
87
Prophylactic measures
Compression stockings, SCD’s, SQ heparin 2-3x/day
- Regional anesthesia can greatly ↓risk d/t earlier postop ambulation
88
Risk and predisposing factors for development of DVT after surgery or trauma picture
89
Anticoagualtion for DVT include:
Warfarin + Heparin or LMWH
90
LMWH advantages over unfractionated heparin
longer HL & more predictable dose response
doesn’t require serial assessment of aPTT
Less risk of bleeding
91
LMWH disadvantages
Higher cost
Lack of reversal agent
92
_____ is initiated during heparin treatment and adjusted to achieve INR btw 2-3
Warfarin
93
What is discontinued when warfarin achieves therapeutic effect?
Heparin
94
IVC filter may be indicated with:
recurrent PE, or contraindication to anticoagulants
95
What is systemic vasculitis?
Group of vascular inflammatory diseases catagorized by the size of the vessels at the primary site of the abnormality
96
Large-artery vasculitis includes:
Takayasu arteritis
Temporal (or giant cell) arteritis
97
Medium-artery vasculitis includes:
Kawasaki disease, which usually affects the coronary arteries
98
Medium to small-artery vasculitis includes:
Thromboangiitis obliterans
Wegener granulomatosis
Polyarteritis nodosa
99
What is temporal (giant cell) arteritis
Symptoms?
Inflammation of arteries of the head and neck
- unilateral; headache, scalp tenderness, jaw claudication
- Opthalmic Arterial branches may lead to ischemic optic neuritis and unilateral blindness
100
Diagnosis and treatment of Temporal (Giant Cell) Arteritis
Biopsy of temporal artery shows arteritis in 90% of pts
corticosteroids indicated for visual symptoms, to prevent blindness
101
What is Thromboangiitis Obliterans Buerger Disease”?
Inflammatory vasculitis leading to small & medium vessel occlusions in the extremities
- Autoimmune response triggered by nicotine
102
____ is the most predisposing factor for Thromboangiitis Obliterans
Most prevalent in ____
Tobacco use
Men <45
103
What are the 5 diagnostic criteria for Thromboangiitis Obliterans?
Diagnosis is confirmed with what?
- 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
104
Symptoms of Thromboangiitis Obliterans
forearm, calf, foot claudication
Ischemia of hands & feet
Ulceration and skin necrosis
Raynaud's is commonly seen
105
Treatment of Thromboangiitis Obliterans
Smoking cessation-most effective tx
Surgical revascularization
No effective pharmacological tx
106
Anesthesia implications of Thromboangiitis Obliterans
Meticulous positioning/padding
Avoid cold; Warm the room and use warming devices
Prefer non-invasive BP and conservative line placement
107
What is polyarteritis nodosa?
This leads to what?
Vasculitis of the small and medium vessels
- glomerulonephritis, myocardial ischemia, peripheral neuropathy and seizures
108
Polyarteritis Nodosa may be associated with what?
Hep B, Hep C, or Hairy Cell Leukemia
109
____ is primary cause of death in Polyarteritis Nodosa
Renal failure
110
Treatment for Polyarteritis Nodosa
steroids, cyclophosphamide, treating underlying cause (s/a cancer)
111
Anesthesia implications for Polyarteritis Nodosa
consider coexisting renal dz, cardiac dz, and HTN
Steroids likely beneficial
112
What is Lower Extremity Chronic Venous Disease?
Long standing venous reflux & dilation
113
Risk factors of Lower Extremity Chronic Venous Disease
advanced age
family hx
pregnancy
ligamentous laicity
previous venous thrombosis
LE injuries
prolonged standing
obesity
smoking
sedentary lifestyle
high estrogen levels
114
Diagnostic criteria of Lower Extremity Chronic Venous Insufficiency
Sx of leg pain, heaviness, fatigue
- Confirmed by ultrasound showing venous reflux
- Retrograde blood flow > 0.5 seconds
115
symptoms of Lower Extremity Chronic Venous Insufficiency
- Mild sx: telangiectasias, varicose veins
- Severe sx: edema, skin changes, ulceration
116
Treatment of Lower Extremity Chronic Venous Insufficiency
Leg elevation
Exercise
Weight loss
Compression therapy
Skin barriers/emollients
Steroids
Wound management
117
Conservative medical management of Lower Extremity Chronic Venous Disease
Diuretics
Aspirin
Antibiotics
Prostacyclin analogues
Zinc sulphate
118
If management of Lower Extremity Chronic Venous Disease fails, ____ may be performed
Ablation
119
Procedures for Lower Extremity Chronic Venous Disease
Saphenous vein inversion
High saphenous ligation
Ambulatory Phlebectomy
Transilluminated-powered phlebectomy
Venous ligation
Perforator ligation
