Vascular Disease - Exam IV Flashcards
1
Q
3 Main Arterial Pathologies:
A
aneurysms, dissections, occlusions
- Aorta & its branches more likely to be affected by aneurysms & dissections
- Peripheral arteries are more likely to be affected by occlusions
2
Q
Aortic aneurysm:
A
Dilation of all 3 layers of artery, leading to a >50% increase in diameter
3
Q
Aortic aneurysm: Sx
A
may be due to compression of surrounding structures
Asymptomatic or pain d/t surrounding compression
4
Q
2 types of Aortic Aneurysms:
A
2 types:
- Saccular: outpouching bulge to one side
- Fusiform: Uniform circumferential dilation
5
Q
Aortic Aneurysms: Diagnostic tools:
A
CT, MRI, CXR, Angiogram, Echocardiogram
*In suspected dissection, doppler echocardiogram is fastest/safest measure of obtaining adiagnosis ofaneurysm
6
Q
Aortic Aneurysms: treatment
A
- Initially treated medically, Medical management to ↓expansion rate
- Manage BP and 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
- Surgery indicated @ >5.5 cm diameter
- Aortic aneurysmrupture is associated with a 75% mortality rate
7
Q
Aortic Dissection
A
- Dissection: Tear in intimal layer of the vessel, causingblood to enter the medial layer
- Ascending dissection: Catastrophic, requiresemergent surgical intervention
-Stanford A, Debakey 1 & 2
-Mortality increases by 1-2% per hr
-Overall mortality 27-58%
8
Q
Aortic Dissection: Sx
A
Severe sharp pain in posterior chest or back
9
Q
Aortic Dissection: Diagnosis:
A
Stable= CXR, CT, MRI, Angiogram
Unstable=Echocardiogram
10
Q
Aortic Aneurysm-Dissection Classification
A
Stanford Class A, B
DeBakey Class 1,2,3
11
Q
Stanford A Dissection
A
- Ascending aorta involved
- Should be considered candidates for surgery
- The most commonly performed procedures:
-ascending aorta & aortic valve replacement w/a composite graft
-ascending aorta replacement with resuspension of the aortic valve
12
Q
Stanford A Dissection w/ aortic arch:
- % seen in pts?
- major complication?
- what does this type of surgery require?
- how is circulatory arrest done?
A
- If Aortic Arch involved: surgical resection isindicated
- Surgery requires 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
-Neurologic deficit is a major complication assoc with aortic arch replacement
-Seen in 3-18% of pts
13
Q
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
14
Q
Stanford B Dissection: Medical therapy consists of:
A
Medical therapy consists of:
1) intraarterial monitoring of SBP and UOP
2) drugs to control BP and the force of LV contraction (BBs, Cardene, SNP)
in-hospital mortality rate of 10%
long-term survival rate with medical tx is 60-80% at 5 yrs and 40-50% at 10 yrs
15
Q
Stanford B Dissection: Surgery
A
Surgery is indicated for type B dissection with signs of impending rupture (persistent pain, hypotension, left-sided hemothorax) or compromised perfusion to the lower body
16
Q
What type of Aortic Dissections require emergent surgery?
A
Ascending arch dissections require emergent surgery
17
Q
descending arch dissections:
When is Sx recommended?
Reason for admission to hospital for?
A
- Descending arch dissections- rarely treated with urgent surgery
- Uncomplicated type B → often admitted for BP control (SA BBs preferred, Aline)
18
Q
Aortic Dissection: sx of impending rupture?
A
Sx of impending rupture (posterior pain, HoTN, hemothorax)→surgical tx
19
Q
Aortic Dissections: Risk Factors?
A
HTN, atherosclerosis, aneurysms, fam hx, cocaine use, & inflammatory diseases
20
Q
Aortic Dissections:Inherited disorders?
A
Inherited disorders: Marfans, Ehlers Danlos, Bicuspid Aortic Valve
21
Q
Aortic Dissections: Causes of dissection?
A
Causes of dissection: blunt trauma, cocaine, iatrogenic (c/b medical treatment)
22
Q
Aortic Dissection: Iatrogenic causes?
A
Iatrogenic causes: cardiac catheterization, aortic manipulation, cross-clamping, arterial incision
23
Q
Aortic Dissection: Dissections are common in?
A
-men
-pregnant women in 3rd trimester
24
Q
Aortic Aneurysm Rupture: A triad of sx seen in about ½ of cases?
A
A triad of sx seen in about ½ of cases:
- Hypotension
- Back pain
- A pulsatile abdominal mass
25
Most abdominal aortic aneurysms rupture into?
Most abdominal aortic aneurysms rupture into the left retroperitoneum
26
Complications of Aortic aneurysm rupture?
- retroperitoneum prevent exsanguination
- If retroperitoneal tamponade occurs, volume resuscitation may be delayed until the rupture is surgically controlled, to maintain a lower BP and reduce risk of further bleeding, hypotension, and death
27
Preoperative Evaluation for aortic aneurysm?
- Assess for presence of CAD, valve dysfunction, heart failure
- Ischemic heart dz may require intervention prior to surgery
- Cardiac evaluation tests: stress test, echocardiogram
- Low FEV1 or renal failure may preclude a pt from aortic resection
- Smoking/COPD = predictors of post aortic surgery respiratory failure
- PFTs & ABGs help define risk
- Consider bronchodilators, abx, chest physiotherapy
28
4 Primary causes of mortality r/t surgeries of thoracic aorta:
4 Primary causes of mortality r/t surgeries of thoracic aorta:
- MI
- Respiratory failure
- Renal failure
- Stroke
29
What is the most significant indicator of post-aortic surgery renal failure?
What to avoid?
What can help in preop?
- the preop renal dysfunctions is the most significant indicator.
- Preop IV hydration - will help with post surgical renal failure
- Avoid hypovolemia
- Avoid HoTN
- Avoid low cardiac output
- Avoid nephrotoxic drugs
30
PreOp eval for aortic aneurysm and Hx of stroke work up include?
h/o stroke or TIA
- Carotid ultrasound
- Angiogram of brachiocephalic & intracranial arteries
Severe carotid stenosis→ workup for CEA. before elective surgery
31
Aortic Aneurysms vs dissections?
32
Anterior Spinal Artery Syndrome
ASA syndrome is caused by lack of blood flow to the anterior spinal artery
The anterior spinal artery perfuses the anterior 2/3 of the spinal cord
33
Anterior Spinal Artery Syndrome: Ischemia of this area leads to?
- loss motor function below the infarct
- diminished pain and temperature
sensation below the infarct
- antonomic dysfunction, leading to hypotension and bowel & bladder dysfunction
34
The most common form of spinal cord ischemia?
- ASA syndrome is the most common form of spinal cord ischemia bc the
ASA has minimal collateral perfusion
- The posterior spinal cord is perfused by two posterior spinal arteries, providing better collateral circulation
35
Common causes of ASA syndrome:
Aortic aneurysms, aortic dissection, atherosclerosis, trauma
36
Cerebral Vascular Accidents: CVA %?
CVA: ischemic (87%) or hemorrhagic (13%)
37
Cerebral Vascular Accidents
CVA:
- Sudden-onset neurological deficits
- Carotid dz is a prominent predictor of CVA
- CVA=1st leading cause of disability in US
- 3rd leading cause of death in US
TIA:
- temporary, self-limited ischemia
- sx resolve within 24h
- TIA’s have 10x greater rx of subsequent stroke
38
Carotid dz- diagnostic testing
Angiography- can dx vascular occlusion
CT & MRI- less invasive, may also identify aneurysms & AVMs
Transcranial doppler US- may give evidence of vascular
occlusions with real-time monitoring
Carotid auscultation- can identify bruits
Carotid US- can quantify degree of carotid stenosis
39
Carotid stenosis commonly occurs at? d/t what cause?
Carotid stenosis commonly occurs at the carotid bifurcation, due to turbulent blood flow at the branch-point
40
Carotid Stenosis: Workup includes:
evaluation for sources of emboli s/a A-fib, heart failure, valvular vegetation
41
Treatment of CVA: TPA?
American Heart Assoc recommends TPA within 4.5h of onset
42
Treatment of CVA
Interventional radiology, carotid endarterectomy, Carotid stenting, and ongoing medical therapy.
43
Interventional radiology for tx of CVA?
Interventional radiology
- intra-arterial thrombolysis
- Intravascular thrombectomy *benefits seen up to 8h after onset of CVA
44
Carotid Endarterectomy (CEA) for tx of CVA?
Carotid Endarterectomy (CEA)
- Surgical treatment for severe carotid stenosis (lumen diameter 1.5mm or >70% blockage)
45
Carotid Stenting for tx of CVA?
Carotid stenting
- Alternative to Carotid Endarterectomy
- Major risk of microembolization→CVA
- Embolic protection devices developed to reduce risk; so far CVA risk still unchanged
46
Ongoing medical therapy for CVA?
Ongoing medical therapy
- Antiplatelet tx
- Smoking cessation
- BP control
- Cholesterol control
- Diet & Physical activity
47
CEA Preop Evaluation: clinical dilemma?
Clinical Dilemma: severe carotid dz + severe coronary artery dz
Must stage cardiac revascularization and CEA
Most compromised area should take priority
48
In CEA: When is it important to maintain collateral blood flow through stenotic vessels?
Maintain collateral blood flow through stenotic vessels, esp during cross-clamp
49
CPP =
MAP - ICP
50
What are cerebral oximetry devices, and what do they help gauge?
Cerebral Oximetry devices (Foresight, INVOS) help gauge and trend cerebral perfusion
51
Pre-op eval of Carotid Endarterectomy (CEA)?
Neurologic eval
- Establish preop deficits (weakness, aphasia, disorientation, etc)
Cardiovascular dz
- CAD is prevalent in carotid dz
- MI is a major cause of perioperative mortality in CEA
HTN-common
- Establish acceptable BP range to optimize CPP during surgery
52
Cerebral Oximetry is affected by?
Cerebral Oxygenation affected by:
MAP
COP
Sa02
HGB
PaC02
53
Cerebral 02 consumption is affected by:
Temperature
Depth Anesthesia
54
Cerebral Oximetry, real-time data link:
https://www.youtube.com/watch?v=YKGavOPJWK0
55
Peripheral Artery Disease
Compromised blood flow to the extremities
56
How is Peripheral Artery Disease (PAD) defined by?
- Defined by an ankle-brachial index (ABI) <0.9
- ABI ratio= SBP @ ankle / SBP @ brachial artery
57
How does Atherosclerosis affect PAD patients?
__x increased risk for MI & CVA with these patients?
Chronic hypo-perfusion is typically due to atherosclerosis
May also be due to vasculitis
Acute occlusions are typically due to embolism
Atherosclerosis is systemic
Pt w/PAD have 3-5x increased risk of MI & CVA
58
Peripheral Artery Disease: Risk Factors?
Advanced age
Family hx
Smoking
DM
HTN
Obesity
↑Cholesterol
59
Peripheral Artery Disease: sxs?
Intermittent claudication
Resting extremity pain
Weak pulses
Subcutaneous atrophy
Hair loss
Coolness
Cyanosis
*Relief w/hanging LE over side of bed (↑hydrostatic pressure)
60
Peripheral Artery Disease Dx
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
61
Peripheral Artery Disease: tx?
Medical Tx: exercise, controlling BP, cholesterol, and glucose
Intervention: revascularization indicated w/disabling claudication or ischemia
- Surgical reconstruction- arterial bypass procedure
- Endovascular repair- angioplasty or stent placement
62
What is Acute Peripheral Artery Occlusion frequently caused by?
Frequently due to cardiogenic embolism
63
Common causes for Acute Peripheral Artery Occlusion?
Common causes:
- Left atrial thrombus d/t Afib
- Left ventricular thrombus d/t cardiomyopathy after MI
64
Acute peripheral artery occlusion: sx?
Sx: limb ischemia, pain/paresthesia, weakness, ↓peripheral pulses, cool skin, color changes distal to occlusion
65
Dx for Acute peripheral artery occlusion?
Dx: Arteriogram
66
Tx for acute peripheral artery occlusion?
Tx: anticoagulation, surgical embolectomy, amputation (last resort)
67
what is Subclavian Steal Syndrome?
SC steal: occluded SCA, proximal to vertebral artery
- vertebral artery flow diverts away from brainstem
68
Subclavian Steal Syndrome: Sx?
Sx: Syncope, vertigo, ataxia, hemiplegia, ipsilateral arm ischemia
Effected arm SBP may be ̴20mmhg lower
Bruit over SCA
69
Risk factors for subclavian steal syndrome?
Risk Factors: atherosclerosis, h/o aortic surgery, Takayasu Arteritis
70
Tx for subclavian steal syndrome?
Tx: SC endarterectomy
71
what is Raynaud's Phenomenon?
Episodic vasospastic ischemia of the digits
72
Raynaud's phenomenon is common in what gender?
Effects women > men
73
Raynaud's Phenomenon: sx?
Sx: digital blanching or cyanosis w/cold exposure or SNS activation
74
Raynaud's Phenomenon: tx?
Tx: protection from cold, CCBs, alpha-blockers
- Surgical sympathectomy for severe ischemia
75
Raynaud's Phenomenon: Dx?
Dx: based on history & physical
76
what are common PVD processes that occur during surgery?
Common PVD processes that occur during surgery:
Superficial thrombophlebitis
Deep vein thrombosis
Chronic venous insufficiency
77
rx factors for thromboembolism?
78
Peripheral Venous Disease & DVT concern?
DVT- major concern bc it can lead to PE, a leading cause of perioperative M & M
79
What is the Virchows triad?
Virchows Triad: 3 factors that predispose to venous thrombosis
-Venous stasis
-Disrupted vascular endothelium
-Hypercoagulability
80
Superficial Thrombophlebitis & DVT:
__% in what surgery?
Superficial Thrombophlebitis & DVT are common in surgery
-occurring in appox 50% total hip replacements
-Normally subclinical and completely resolves
81
What is DVT associated with? sxs?
DVT associated with extremity pain and swelling
82
Risk factors for DVT?
risk factors: >age 40, surgery >1h, cancer, ortho surgeries on pelvis & LEs, abdominal surgery
83
Dx for DVT?
Dx: Doppler U/S, venography, impedance plethysmography
84
Prophylactic measures for Superficial Thrombophlebitis & DVT?
Prophylactic measures:
Compression stockings, SCD’s, SQ heparin 2-3x/day
- Regional anesthesia can greatly ↓risk d/t earlier postop ambulation
85
DVT treatment
Anticoagulation: Warfarin + Heparin or LMWH
- LMWH advantages over unfractionated heparin
- longer HL & more predictable dose response
- doesn’t require serial assessment of aPTT
- Less risk of bleeding
LMWH disadvantages
- Higher cost
- Lack of reversal agent
86
DVT Treatment: when do we d/c heparin?
Heparin discontinued when Warfarin achieves therapeutic effect
87
DVT: how long is PO anticoagulant continued for?
PO anticoagulants continued for 6 months or longer.
88
When do patients get IVC filters?
IVC filter may be indicated w/ recurrent PE, or contraindication to anticoagulants
89
DVT treatment: what is the INR goal with warfarin?
Warfarin (vit K antagonist) is initiated during heparin treatment and adjusted to achieve INR btw 2-3
90
What is Systemic Vasculitis?
Group of vascular inflammatory diseases catagorized by the size of the vessels at the primary site of the abnormality
91
Large-artery vasculitis includes:
- Takayasu arteritis
- Temporal (or giant cell) arteritis
92
Medium-artery vasculitis includes:
Kawasaki disease, which usually affects the coronary arteries
93
Medium to small-artery vasculitis includes:
Thromboangiitis obliterans
Wegener granulomatosis
Polyarteritis nodosa
94
What is Temporal (Giant Cell) Arteritis?
Inflammation of arteries of the head and neck
95
Temporal (Giant Cell) Arteritis sx?
Sx: unilateral; headache, scalp tenderness, jaw claudication
-Opthalmic Arterial branches may lead to ischemic optic neuritis and unilateral blindness
96
Temporal (Giant Cell) Arteritis: Dx?
Dx: Biopsy of temporal artery shows arteritis in 90% of pts
97
Temporal (Giant Cell) Arteritis: tx?
Tx: corticosteroids indicated for visual symptoms, to prevent blindness
98
What is Thromboangiitis Obliterans? Is it “Buerger Disease”?
Inflammatory vasculitis leading to small & medium vessel occlusions in the extremities, aka buerger disease
Autoimmune response triggered by nicotine
Tobacco use is most predisposing factor
99
Thromboangiitis Obliterans “Buerger Disease”: diagnostic criteria?
5 diagnostic criteria:
- h/o smoking
- onset before 50
- infrapopliteal arterial occlusive dz
- upper limb involvement
- Absence of risks factors for atherosclerosis (outside of tobacco)
Diagnosis confirmed w/biopsy of vascular lesions
100
Thromboangiitis Obliterans “Buerger Disease”: most prevalent in?
Most prevalent in men <45
101
Buerger Disease: symptoms?
Symptoms:
-forearm, calf, foot claudication
-Ischemia of hands & feet
-Ulceration and skin necrosis
-Raynaud's is commonly seen
102
Buerger Disease: treatment?
Treatment:
- Smoking cessation-most effective tx
- Surgical revascularization
- No effective pharmacological tx
103
Buerger Disease: anesthesia implications?
Anesthesia implications:
- Meticulous positioning/padding
- Avoid cold; Warm the room and use warming devices
- Prefer non-invasive BP and conservative line placement
104
What is Polyarteritis Nodosa?
- Vasculitis of the small and medium vessels
- Leads to glomerulonephritis, myocardial ischemia, peripheral neuropathy and seizures
-HTN generally caused by renal dz
-Renal failure is the primary cause of death
105
What could be associated with polyarteritis nodosa?
May be assoc w/ Hep B, Hep C, or Hairy Cell Leukemia
106
Polyarteritis Nodosa: tx?
Tx: steroids, cyclophosphamide, treating underlying cause (s/a cancer)
107
Polyarteritis nodosa: Anesthesia Implications?
Anesthesia Implications:
- Consider coexisting renal dz, cardiac dz, and HTN
- Steroids likely beneficial
108
Lower Extremity Chronic Venous Disease: risk factors?
Risk factors:
advanced age
family hx
pregnancy
ligamentous laicity
previous venous thrombosis
LE injuries
prolonged standing
obesity
smoking
sedentary lifestyle
high estrogen levels
109
What are the ranges for Lower Extremity Chronic Venous Disease?
Ranges mild-severe:
Mild sx: telangiectasias, varicose veins
Severe sx: edema, skin changes, ulceration
110
What is lower extremity chronic venous disease?
-Long-standing venous reflux & dilation
-Effects 50% of the population
111
Lower Extremity Chronic Venous Insufficiency: Diagnostic criteria?
Diagnostic criteria: Sx of leg pain, heaviness, fatigue
- Confirmed by ultrasound showing venous reflux
- Retrograde blood flow > 0.5 seconds
112
Lower extremity chronic venous insufficiency: Tx?
Treatment: initially conservative
Leg elevation
Exercise
Weight loss
Compression therapy
Skin barriers/emollients
Steroids
Wound management
113
Lower Extremity Chronic Venous Disease: Conservative medical management?
Conservative medical management:
Diuretics
Aspirin
Antibiotics
Prostacyclin analogues
Zinc sulphate
*If management fails, ablation may be performed
114
Lower Extremity Chronic Venous Disease: when is surgical intervention indicated?
Surgical intervention- usually last resort
115
Lower Extremity Chronic Venous Disease: surgical procedures:
Procedures:
-Saphenous vein inversion
-High saphenous ligation
-Ambulatory Phlebectomy
-Transilluminated-powered phlebectomy
-Venous ligation
-Perforator ligation
