Vascular Disease (Exam III) Flashcards
What are some coexisting diseases that are commonly seen in vascular surgery patients? Which 3 are the MOST common?
- CAD - 40-80% of vasc patient have this
- HTN- (most common)
- Diabetes- (most common)
- Smokers- (most common)
- CNS atherosclerosis
- Renal
Good to know - From Brooke
What are the 3 main arterial Pathologies?
aneurysms, dissections, occlusions
- Aorta and its branches are more likely to be affected by aneurysms and dissections
- Peripheral arteries are more likely to be affected by occlusions
slide 3
2 types of aortic aneurysms
- fusiform: uniform dialation along the entire corcumference of the arterial wall
- saccular: berry-shaped bulge to one side
slide 4
Signs and symptomes of aortic aneurysms, and diagnostic tools
- s/s: can be asymptomatic or can have pain due to surrounding compression
- diagnostic tools: CT, MRI, CXR, angiogram, echo (in a suspected dissection, a doppler echocardiogram is the fastest and safest measure to diagnose)
slide 4
Treatment of aortic aneurysms
- 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, or a family history of dissection
- Endovascular stent repair has become a mainstay over open surgery w/graft
slide 5
What are the risk factors for vascular disease?
- Diabetes mellitus
- Dyslipidemia
- Family history
- Hypertension
- Obesity
- Older age: 75 y/o and up
- Smoking (2x)
In a patient with vascular disease what other issues should we be sure to evaluate in preop? Why does it matter?
- CAD
- pulm dysfunction
- renal dysfunction
- neuro dysfunction
- endocrine dysfunction
- Matters d/t disease process not being limited to arterial beds in periphery → its everywhere
from Brooke, good to know
What is the primary goal for invasive monitoring of a vascular surg patient?
To detect cardiac problems; a-line might be necessary
from Brooke
Peripheral Venous Disease (common processes that occur during surgery)
- Superficial thrombophlebitis
- Chronic venous insufficiency
- DVT- major concern bc it can lead to PE, a leading cause of perioperative M & M
- Virchows Triad: 3 major factors that predispose to venous thrombosis
Venous stasis
Hypercoagulability
Disrupted vascular endothelium
Sldie 30
Superficial Thrombophlebitis and DVT are common in surgery.
Occur in approximately _ total hip replacements
Normally _ and usually _
* Risk factors for DVT:
- 50%
- subclinical and usually completely resolve
- Risk factors: >age 40, surgery >1h, cancer, ortho surgeries on pelvis & LEs, abdominal surgery
slide 31
Diagnostics and Prophylactic measures for SVT and DVT
- Diagnostics: Doppler U/S sensitive for detecting proximal thrombosis > distal thrombosis, Venography and impedance plethysmography are also useful diagnostic tools
-
Prophylactic measures: SCD’s, SQ heparin 2-3x/day
Regional anesthesia can greatly ↓risk d/t earlier postop ambulation
slide 31
DVT treatment
- Anticoagulation: Warfarin + Heparin or LMWH
- Warfarin (vit K antagonist) is initiated during heparin treatment and adjusted to achieve INR btw 2-3
- Heparin discontinued when Warfarin achieves therapeutic effect
- PO anticoagulants continued 6 months or longer
An IVC filter may be placed in pts w/ recurrent PE, or have contraindication to anticoagulants
slide 34
LMWH advantages and disadvantages
-
Advantages: longer HL & more predictable dose response,
doesn’t require serial assessment of activated partial thromboplastin time, Less risk of bleeding - Disadvantages: Higher cost, Lack of reversal agent
slide 34
What causes intermittent claudication?
- When O₂ demand exceeds supply
from Brooke
When might revascularization for PVD be considered?
- Disabling claudication
- Ischemic rest pain
- Impending limb loss
from Brooke
What are risk factors for stroke?
- Age;
- Atrial fibrillation;
- Black race;
- History/family history;
- HTN/smoking/diabetes;
- Hypercholesterolemia;
- Male;
- Obesity;
- Sickle cell disease
from brooke
What are some ways we might diagnose a stroke?
- Angiography;
- Carotid bruit with auscultation
- Carotid stenosis;
- Sudden neurological deficits
slide 18 and 19
Where does carotid stenosis most often occur? and what should our workup include?
Carotid bifurcation
due to turbulent blood flow at the branch point
* Workup includes: evaluation for sources of emboli (AFib), heart failure, valvular vegitation, or paradoxical emboli
slide 19
Treatment of CVA
- AHA recommends TPA withing 4-5Hours
- IR
- Carotid Endarterectomy (CEA) - lumen diameter 1.5mm or >70% blockage
- Carotid stenting (alternative to CEA) major risk for microembolization
- Ongoing medical treatment: antiplatelet agents, smoking cessation, BP control, cholesterol control, diet and physical activity
slide 20
CEA preop evaluation
- Neuro eval
- CV disease (CAD is prevalent, MI is a major cause of complications in the OR_)
- HTN is common - establish an acceptable BP range
- CPP=MAP-ICP
- Maintain collateral flow through stenotic vessels
- extreme head rotation may compress blood flow
- cerebral oximetry divices to determine perfusion
slide 21
Cerebral oximetry - real time data
Effected by: MAP, CO,SaO2, HGB, PaCO2
cerebral O2 consumption effected by: temp and anesthesia
slide 22
Peripheral artery disease
Compromised blood flow to the extremities
* defined by ankle-brachial index (ABI) <0.9
* ratio = SBP at ankle: SBP at brachilal artery
* chronic hypoperfusion due to atherosclerosis or vasculitis
slide 23
PAD acute occlusions are typically due to _
Incidence of PAD increases with _, exceeding 70% by _
Atherosclerosis is _, a pt with PAD has _ increased risk of _ and _
- embolism
- age 70
- systemic, 3-5x, MI and CVA
slide 23
Peripheral Artery disease Risk factors
- advanced age
- family history
- smoking
- DM
- HTN
- obersity
- increased cholesterol
slide 24
Peripheral artery disease signs and symptoms
- intermittent claudication
- resting extremity pain
- decreased pulses
- subcutaneius atrophy
- hair loss
- coolness
- cyanosis
- relief with hanging lower extremity over the side of the bed to increase hydrostatic pressure
slide 24
Diagnosis and treatment of PAD
Diagnosis: Doppler US, Duplex US (can ID areas of plaque formation), transcutansius oximetry, MRI with contrast to guide intervention or sugical bypass
Treatement: exercise, BP cholesterol and glucose control, revascularization is indicated with disabling claudication
* surgical reconstruction - bypass
* endovascular repair - transluminal angioplasty or stent placement
slide 25
Acute artery occlusion (due to what? and causes)
frequently d/t cardiogenic embolism
* common causes: Left atrial thrombus arising from Afib, Left ventricular thrombus arising from dilated cardiomyopathy after MI
* Less common causes: valvular heart dz, endocarditis, PFO, atheroemboli, plaque rupture, hypercoagulability, trauma
slide 26
Acute artery occlusion (s/s, diagnosis and treatment)
- s/s: limb ischemia, pain/paresthesia, weakness, ↓peripheral pulses, cool skin, color changes distal to occlusion
- Diagnosis: Arteriography
- Treatment: Surgical embolectomy, anticoagulation, amputation (last resort)
slide 26
Subclavian Steal Syndrome (definition, s/s)
- occluded SCA, proximal to vertebral artery causing vertebral artery blood flow to be diverted away from brainstem
- s/s: Syncope, vertigo, ataxia, hemiplegia, ipsilateral arm ischemia
Effected arm SBP may be ̴20mmhg lower
Bruit over subclavian artery
slide 27
Subclavian steal syndrome (risk factors and treatment)
Risk factors: Atherosclerosis, Takayasu Arteritis, aortic surgery
Treatment: stents or sx (its curative)
slide 27
Raynaud’s Phenomenon (definition, s/s)
Episodic vasospastic ischemia of the digits
Effects women > men
May appear with CREST syndrome (scleroderma subtype)
* S/S: digital blanching or cyanosis w/cold exposure or SNS activation
slide 29
Raynaud’s Phenomenon (diagnosis and treamtent)
- Diagnosis: based on history and physical
- Treamtent: protection from cold, CCB’s, alpha blockers, Surgical sympathectomy for severe ischemia
slide 29
Carotid disease diagnostic testing
- angiography
- CT/MRI
- Transcranial doppler US: may give indirect evidence of vascular occlusions
- carotid auscultation
- carotid US
slide 19
Systemic Vasculitis (definition)
- 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
slide 35
How are aortic dissections classified?
- DeBakey I II III;
- –OR–;
- Stanford A (proximal) or B (Distal)
Describe each of the DeBakey classifications?
- DeBakey I → Dissection in the ascending aorta that extends into the descending aorta;
- DeBakey II → Dissection in the ascending aorta that does notextend into the descending aorta;
- Debakey III → Dissection in the descending aorta distal to left subclavian;
- Debakey IIIA → extension to abdominal aorta;
- Debakey IIIB → doesn’t extend to abdominal aorta
Comparison of Aortic Aneurysm and Aortic Dissection
