Vascular Disease (Exam IV)-Mordekai Flashcards
1
Q
What are the 3 main arterial pathologies for vascular disease?
A
- Aneurysm
- dissection
- occlusion
2
Q
What type of vascular disease is more likely to be affected by aneurysms and dissections?
A
The aorta and its branches
3
Q
What type of vasculature is more likely to be affected by occlusions?
A
peripheral arteries
4
Q
What is an aortic aneurysm?
A
*A bulge in a section of the aorta caused by an underlying weakness in the aortic wall.
* Dilation of all 3 layers of an artery leading to a >50% increase in diameter.
* Symptoms may be due to compression of surrounding structures.
5
Q
When is surgery indicated for an aortic aneurysm?
A
- When it is >5.5 cm in diameter
- When there has been >10mm of growth per year
- When there is a family history of dissection.
6
Q
What is the mortality rate if an aortic aneurysm ruptures?
A
75%
7
Q
How is an aortic aneurysm treated?
A
- Medical management to decrease expansion rate (initial treatment)
- Manage BP, cholesterol, and smoking cessation
- Avoid strenuous exercise, stimulants, and stress
- Routine/regular monitoring for progression of aneurysm.
- Proceed to surgery if aneurysm is >5.5cm, there has been growth of >10mm in a year, or there is a family history of dissection.
- Endovascular stent repair.
8
Q
True/False
Endovascular stent repair has become the mainstay over open surgery with graft in the treatment of an aortic aneurysm.
A
True
9
Q
What are the 2 types of aortic aneurysms?
A
- Fusiform
- Saccular
10
Q
What is a fusiform aortic aneurysm?
A
Uniform dilation along the entire circumference of the arterial wall.
11
Q
What is a saccular aortic aneurysm?
A
A berry shaped bulge to one side of the aorta.
12
Q
What are the S/S of an unruptured (Fusiform or Saccular) aneurysm?
A
Asymptomatic or pain due to surrounding compression.
13
Q
How can an aortic aneurysm be diagnosed?
A
- CT
- MRI
- Chest x-ray
- Angiogram
- Echocardiogram
14
Q
What is the fastest and safest tool used to diagnose a suspected aortic aneurysm dissection?
A
Doppler echocardiogram
15
Q
- What is an aortic dissection?
- What are the S/S?
- How is it diagnosed?
A
- A tear in the intimal layer of the vessel causing blood to enter the medial layer of the aorta.
- S/S - severe sharp pain in the posterior chest or back.
- Diagnosis - Stable = CT. MRI, chest x-ray, angiogram. Unstable = echocardiogram
16
Q
- What type of aortic dissection is catastrophic and requires emergent surgical intervention?
- What are the classifications of this type of dissection?
- At what rate does the mortality increase?
- What is the overall mortality of this type of aneurysm?
A
- Ascending aortic dissection
- Stanford A, Debakey 1, Debakey 2
- Mortality rate increases by 1-2% per hour
- Overall mortality = 27-58%
17
Q
What are the 2 types of aortic aneurysm dissection classes?
A
- Stanford class (A and B)
- DeBakey class (I, II, and III)
18
Q
Label the aortic aneurysm dissection classes.
A
19
Q
Label the aortic aneurysm dissection classes
A
20
Q
What is a DeBakey type-I aortic aneurysm dissection?
A
A tear in the ascending aorta that propogates to the aortic arch
21
Q
What is a DeBakey type-II aortic aneurysm dissection?
A
A tear confined to the ascending aorta
22
Q
What is a DeBakey type-III aortic aneurysm dissection?
A
A tear in the descending aorta
23
Q
What is a Stanford B aortic aneurysm dissection?
A
A tear in the ascending aorta
24
Q
What is a Stanford B aortic aneurysm dissection?
A
A tear in the descending aorta
25
* What is the first type of Stanford A aortic aneurysm dissection?
* What are the most commonly performed procedures for this type?
* A dissection involving the ascending aorta.
* All patients with an acute dissection involving the ascending aorta should be considered candidates for surgery.
* The most commonly performed procedures include ascending aorta and aortic valve replacement with a composite graft, and replacement of the ascending aorta and resuspension of the aortic valve.
26
* What is the second type of Stanford A aortic aneurysm dissection?
* What type of surgery is used for this type of dissection?
* What are the major complications associated with replacement/surgery of this type of dissection?
* A dissection involving the aortic arch. In patients with acute aortic arch dissection, resection of the aortic arch is indicated.
* Surgery requires cardiopulmonary bypass, profound hypothermia, and a period of circulatory arrest. With current techniques, a period of circulatory arrest of 30-40 minutes at a body temperature of 15-18C can be tolerated by most patients.
* Neurologic deficits are the major complications associated with replacement of the aortic arch. These occur in 3-18% of patients, and it appears that selective antegrade cerebral perfusion decreases but does not completely eliminate the morbidity and mortality associated with this procedure.
27
* What area of the aorta does a StanFord B aortic aneurysm involve?
* What is the initial treatment for this type of dissection?
* What does medical management of this type of dissection involve?
* What is the mortality rate?
* When is surgery indicated for this type of aneurysm?
* What is the mortality rate when surgical treatment is used for this type of aneurysm?
* Descending thoracic aorta.
* Patients with an acute, but uncomplicated type B aortic dissection who have normal hemodynamics, no periaortic hematoma, and no branch vessel involvement can be treated with medical therapy.
* Medical therapy consists of intraarterial monitoring of blood pressure, UOP monitoring, drugs to control BP and the force of LV contraction with BBs, cardene, and nipride.
* This patient population has an in-hospital mortality rate of 10% when medically managed, and 29% when surgically managed. The long-term survival rate with medical therapy is only 60-80% at 5 years and 40-50% at 10 years.
* Surgery is indicated for patients with type B aortic dissection who have signs of impending rupture (persistant pain, hypotension, and left sided hemothorax); ischemia of the legs, abdominal viscera, spinal cord, and renal failure.
28
Which type of aortic dissection requires emergent surgery?
Ascending arch dissection
29
Which type of aortic dissection is rarely treated with urgent surgery?
* Descending arch dissections.
* An uncomplicated type B dissection is often admitted for BP control using beta blockers.
* Symptoms of impending rupture (posterior pain, hypotension, hemothorax) will require surgical intervention.
30
What are risk factors for aortic dissections?
* Hypertension
* Atherosclerosis
* Aneurysms
* family history
* cocaine use
* inflammatory diseases
31
What inherited disorders have a risk factor for aortic dissections?
* Marfans
* Ehlers Danlos
* Bicuspid aortic valve
* non-syndrome familial history
32
What are causes of aortic dissections?
* Blunt trauma
* cocaine
* iatrogenic caused by medical treatment (cardiac cath, aortic manipulation, cross clamping, and arterial incision)
33
What 2 patient populations are aortic dissections more common in?
* Men
* pregnant women in their 3rd trimester
34
What are the signs and symptoms of aortic aneurysm rupture?
* Hypotension
* back pain
* Pulsitile abdomonal mass
* These symptoms occur in 50% of the cases.
35
Where do most aortic aneurysms rupture?
Into the left retroperitoneum
36
Although hypovolemic shock may be present, how can exanguination in aortic aneurysm rumpture patients be prevented?
by clotting and the tampenade effect in the retroperitoneum.
37
Why is euvolemic resuscitation deferred until the aortic aneurysm rupture is surgically controlled?
Because euvolemic resuscitaiton and the resulting increase in blood pressure without control of bleeding may lead to loss of retroperitoneal tampenade, further bleeding, hypotension, and death.
38
What are the 4 primary causes of mortality related to surgeries of the thoracic aorta?
* MI
* Respiratory failure
* Renal failure
* Stroke
39
What is included in a pre-op evaluation for a thoracic aorta?
* Assess for presence of CAD, valve dysfunction, and heart failure
* Ischemic heart disease may require intervention prior to surgery.
* Get pre-op cardiac evaluation test: stress test, echo, radionuclide imaging.
* Severe reduction in FEV1 or renal failure may preclude a patient from AAA resection.
* Smoking/COPD = predictors of post aortic surgery respiratory failure. PFTs and ABGs help define risk.
* Consider bronchodilators, antibiotics, and chest physiotherapy.
* **Pre-op renal dysfunction is the most important indicator of post-aortic surgery renal failure (pre-op hydration, avoid hypovolemia, hypotension, and low CO, avoid nephrotoxic drugs)**
* If they have a history of stroke or TIA get a cardiac ultrasound, and an angiogram of brachiocephalic and intracranial arteries.
* If they have severe caraotid stenosis recommend workup for CEA before elective surgery
40
What is anterior spinal syndrome?
* Caused by lack of blood flow to the anterior spinal artery
* The anterior spinal artery is responsible for perfusing the anterior 2/3rds of the spinal cord.
* Ischemia of this area leads to loss of motor function below the infarct, dimineshed pain and temperature sensation below the infarct, and autonomic dysfunction leading to hypotension and loss of bowel and bladder function.
* Anterior spinal artery syndrome is the most common form of spinal cord ischemia because the anterior spinal artery has minimal collateral perfusion, making it particularly vulnerable. (the posterior spinal cord is perfused by 2 posterior apinal arteries, allowing for better collateral circulation)
41
What are common causes of anterior spinal artery syndrome?
* Aortic aneurysms
* aortic dissections
* atheresclerosis
* trauma
42
* What are the 2 types of CVAs and what percentage is their incidence?
* What are the signs of a CVA?
* Ischemic - 87%
* Hemorrhagic - 13%
* Sudden onset neurological defecits
43
What are the inherited risk factors of a CVA?
* age
* prior history of a stroke
* family history of a stroke
* black race
* male gender
* sickle cell disease
44
What are the modifiable risk factors of a stroke?
* elevated blood pressure
* smoking
* diabetes
* carotid artery disease
* a-fib
* heart failure
* hypercholesterolemia
* obesity
* physical inactivity
45
A CVA is the ____ leading cause of dissability and _____ leading cause of death in the U.S.
* 1st
* 3rd
46
* What is a TIA?
* When do symptoms resolve?
* What is a TIA a risk factor for?
* A subset of self-limited ischemic strokes
* symptoms resolve within 24 hours
* TIA's have a 10x greater risk of developing a subsequent stroke
47
What type of carotid disease is angiography diagnostic testing used for?
Can diagnose vascular occlusions
48
What type of carotid disease is an MRI or CT diagnostic testing used for?
* Less invasive
* May be used to identify aneurysms and AVMs
49
What type of carotid disease is a transcranial doppler ultrasound diagnostic testing used for?
* May give indirect evidence of vascular occlusions with real time bedside monitoring
50
What type of carotid disease is carotid auscultation diagnostic testing used for?
can identify bruits
51
What type of carotid disease is carotid ultrasound diagnostic testing used for?
can quantify degree of carotid stenosis
52
Where does carotid stenosis most commonly occur?
* At the internal/external carotid bifurcation due to turbulent blood flow at the branch point
53
What does the work-up for carotid stenosis include?
* Evaluation for sources of emboli, a-fib, heart failure, valvular vegetation, or paradoxical emboli in the setting of PFO.
54
What are the treatments for a CEA?
* **TPA** within 4.5 hours
* **IR **for intra-arterial thrombolysis or intravascular thrombectomy (benefits seen up to 8 hours after onset of CVA)
* **Carotid endartorectomy **- aurgical treatment for severe carotid stenosis with a lumen diameter greater than 1.5mm or >70% blockage
* **Carotid stenting **- alternative to a CEA, has a mjaor risk for microembilization which could lead to another CVA, embolic protection devices have been developed to mitigate risk but so far CVA risk is still unchanged.
* **Ongoing medical therapy **- antiplatelet treatment, smoke cessation, BP control, cholesterol control, diet and physical activity.
55
What is done in a carotid endartorectomy pre-op evaluation?
* Neuro exam - establish preop defecits, weakness in extremities, aphasia, disorientation, etc.
* Cardiovascular disease - CAD is prevelent in carotid disease patients. an MI is a mjaor cause of perioperative mortality and morbidity in CEA's.
* Hypertension - very common, establish acceptable BP range to optimize CPP during surgery.
* CPP = MAP - ICP
* Maintain collateral blood flow through stenotic vessels, especially during cross-clamping.
* Extreme head rotation/ flexion/ or extension may compress collateral artery flow
* Cerebral oximetry devicesare useful in determining cerebral perfusion.
* Clinical dilema - for severe carotid disease + severe CAD, you must stage cardiac revasculaization and CEA. The most compromised area should take priority
56
What is cerebral oxygenation affected by?
* MAP
* COP
* SaO2
* Hemoglobin
* PaCO2
57
What is cerebral oxygen consumption effected by?
* Temperature
* anesthesia
58
What is peripheral artery disease?
* Results in compromised blood flow to the extremities
* Defined by and ankle-brachial index of <0.9. ABI = ratio of SBP atthe ankle to the SBP at the brachial artery
* Chronic hypoperfusion to the extremity is typically due to atheroclerosis but may also be due to vasculitis
* Acute occlusions are typically due to an embolism.
* Atherosclerosis is systemic.
59
Incidence of peripheral artery disease increases with age, exceeding _____% by age _____.
* 70%
* age 75
60
Patients with peripheral artery disease have a 3-5x increased risk of what 2 things?
* MI
* CVA
61
What are the risk factors for PAD?
* advanced age
* family history
* smoking
* diabetes
* Hypertension
* Obesity
* High cholesterol
62
What are the signs and symptoms of PAD?
* Intermittent claudication
* resting extremity pain
* decreased pulses
* subcutaneous atrophy
* hair loss
* coolness
* cyanosis
* relief with hanging leg over the side of the bed which increases hydrostatic pressure
63
What tests are used to diagnose PAD?
* Doppler ultrasound - provides a pulse volume waveform and identifies arterial stenosis
* Duplex ultrasound - can identify areas of plaque formation and calcification
* Transcutaneous oximetry - Can assess the severity of tissue ischemia
* MRI with contrast angiography - used to guide endovascular intervention or surgical bypass
64
What are the treatments for PAD?
* Medical treatment - exercise, BP control, cholesterol control, and glucose control.
* Medical intervention - revascularization indicated with disabling claudication or ischemia.
* Surgical reconstruction - arterial bypass procedure
* Endovascular repair - transluminal angioplasty or stent placement.
65
What are the most common causes of acute artery occlusions?
* Left atrial thrombus arising from a-fib
* left ventricular thrombus arising from dilated cardiomyopathy after an MI
66
What are some less common acute artery occlusion causes?
* Valvular heart disease
* Endocarditis
* PFO
* atheroemboli
* plaque rupture
* hypercoagulability
* trauma
67
What are the signs and signs and symtpoms of acute artery occlusion?
* Limb ischemia
* pain/paresthia
* weakness
* decreased peripheral pulses
* cool skin
* color changes distal to occlusion
68
How is acute artery occlusion diagnosed?
arteriography
69
What is subclavian steal syndrome?
* An occluded SCA proximal to the vertebral artery causing vertebral artery blood flow to be diverted away from the brainstem.
70
What are the symptoms of subclavian steel syndrome?
* Syncope
* vertigo
* ataxia
* hemiplegia
* ipsilateral arm ischemia
* effected arm SBP may be 20mmHg lower
* bruit over SCA
71
What re the risk factors for subclavian steal syndrome?
* atherosclerosis
* Takayasu arteritis
* aortic surgery
72
What is the treatment for subclavian steal syndrome?
Subclavian endarterectomy is curative
73
* What is Raynauds phenomenon?
* What population does it affect more?
* What are the signs and symptoms?
* How is it diagnosed?
* What are the treatments?
* Raynauds is episodic vasospastic ischemia of the digits
* Effects women more than men
* S/S = digital blanching or cyanosis with cold exposure or SNS activation
* Diagnosed based on history and physical
* Treatment = protection from cold, calcium channel blockers, alpha blockers, surgical sympathectomy for severe ischemia.
74
What other syndrome wil Raynauds phenomenon appear with?
CREST syndrome, a scleroderma subtype
75
What are 3 common PVD processes that occur during surgery?
* Superficial thrombophlebitis
* Deep vein thrombosis
* Chronic venous insufficiency
76
A DVT is a major concern because it can lead to a ___ which is a leading cause of ____.
* Pulmonary embolism
* perioperative morbidity and mortality
77
What is virchows triad?
* The three major factors that predispose a patient to venous thrombosis
* Venous stasis
* Hypercoagulability
* Disrupted vascular endothelium
78
What 2 main symtpoms are DVTs associated with?
* Extremity pain
* Extremity swelling
79
True/False
Superficial thrombophlebitis and DVTs are common in surgery.
* True
* These occur in approximately 50% of total hip replacements
* They are normally and completely resolve.
80
What increases the risk factor for getting a DVT in the OR?
* Being over the age of 40
* Surgery greater than 1 hour
* cancer
* Ortho surgeries on the pelvis or lower extremities
* abdominal surgery
81
What tests are used to diagnose DVTs?
* Doppler ultrasound sensative for detecting proximal thrombosis greater than distal thrombosis.
* Venography and impedance plethysmography are also useful diagnostic tools
82
What are the top 2 prophylactic measures used to prevent DVTs?
* SCDs
* SubQ heparin 2-3x daily
83
What type of anesthesia can greatly decrease the risk of intra-op DVTs?
Regional anesthesia due to patients recovering from anesthesia quicker and earlier post-op ambulation
84
What is the treatment for DVTs?
* Anticoagulation (warfarin, heperain, LMWH).
* Warfarin (vitamin K antagonist) is initiated during heparin treatment and adjusted to achieve INR between 2-3.
* Heparin is discontinued when warfarin acheives therapeutic effect.
* PO anticoagulatns are continued for 6 months or longer
* An IVC filter may be placed in patients with recurrent PE, or those that have a contraindication to anticoagulants.
85
What is systemic vasculitis
* A diverse group of vascular inflammatory dieases with characteristics that are often grouped by the size of the vessels at the primary site of the abnormality
* Vasculitis can be a feature of connective tissue diseases such as systemic lupus erythematosus and rheumatoid arthritis.
86
What does large artery vasculitis include?
* Takayasu arteritis
* Temporal or giant cell arteritis
87
What does medium artery vasculitis include?
Kawasaki disease,w hich is most prominently in the coronary arteries
88
What does medium to small artery vasculitis include?
* Thromboangitis obliterans
* Wegener granulomatosis
* Polyarteritis nodosa
89
* What is temporal giant cell arteritis?
* What are the S/S?
* How is it diagnosed?
* What is the treatment?
* Inflammation of tthe arteries of the head and neck. Typically affects people over the age of 50. Closely linked with polymyalgia rheumatica
* S/S - unilateral headache, scalp tenderness, and jaw claudication. Opthalmic arterial branches may lead to ischemic optic neuritis and unilateral blindness.
* Diagnosed - biopsy of temperoal artery shows arteritis in 90% of patients.
* Treatment - prompt initiation of corticosteroids indicated for visual symptoms, to prevent blindness
90
* What is thromboangitis obliterans? AKA Buerger disease
* What are the signs and symptoms?
* How is it diagnosed and what are the 5 diagnostic criteria?
* What is the treatment?
* What are the anesthesia implications?
* Inflammatory vascultitis leading to small and medium vessel occlusions in the extremities. Autoimmune response is triggered by nicotine. Tobacco use is the most predisposing factor. Most prevelent in men younger than 45.
* S/S - forearm, calf, or foot claudication, ischemia of hands and feet, ulceration and skin necrosis, Raynauds is commonly seen.
* Diagnosis - confirmed with biopsy of vascular lesions. 5 diagnostic criteria include history of smoking, onset before 50 years old, infrapopliteal arterial occlusive disease, upper limb involvement, and absence of risk factors for atherosclerosis (outside of smoking).
* Treatment - Smoking cessation is the most effective, surgical revascularization, no effective pharmacological treatment.
* Anesthesia implications - meticulous positioning/padding, avoid cold, warm the room and use warming devices, prefer non-invasive BP and conservative line placement
91
* What is polyarteritis Nodosa?
* What are the sings and symptoms?
* What are the treatments?
* What are the anesthesia considerations?
* Antimeutrophyl cytoplasmic antibody (ANCA) negative vasculitis. May be associated with hep B, hep C, or hairy cell leukemia. Small and medium arteries are involved.
* S/S - inflammation results in glomerulonephritis, myocardial ischemia, and peripheral neurophathy and seizures. Hypertension is generally caused by the glomerulonephritis. Renal failure is the primary cause of death in these patients.
* Treatment - steroids, cyclophosphamide, treating underlying causes (s/a cancer).
* Anesthesia considerations - consider coexisting renal disease, cardiac disease, and hypertension. Steroids are likely beneficial for these patients.
92
What is lower extremity chronic venous disease?
* Long standing venous reflux and dilation that effects 50% of the population.
93
What are the S/S of lower extremity chronic venous insufficiency disease?
* S/S range from mild to severe.
* Mild - telangiectasis, varicose veins, burning, tingliing, or pins, and needles in your legs, flaking or itching skin on your legs and feet, leathery looking skin on legs and feet.
* Severe - edema, skin changes, ulceration, achy or tired legs, cramping in your legs at night, full or heavy feeling in your legs.
94
What are the risk factors for lower extremity chronic venous insufficiency disease?
* Advanced age
* family history
* preganancy
* ligamentous laicity
* previous venous thrombosis
* lower extremity injuries
* prolonged standing
* obesity
* smoking
* sedentary lifestyles
* high estrogen levels
95
How is lower extremity chronic venous insufficiency disease diagnosed?
* Symptoms of leg pain, heavyness, and fatigue.
* Confirmed by ultrasound showing venous reflux
* Retrograde blood flow is greater than 0.5 seconds
96
How is lower extremity chronic venous insufficiency disease treated?
* Treatment is initially conserative with - leg elevation, exercise, weight loss, compression therapy, skin barriers/emollients, steroids, and wound management.
* COnservative medical management includes - diuretics, aspirin, antibiotics, prostacyclin analogues, zinc sulphate.
* If medical management fails, ablation may be performed.
* Surgical interventions are done as a last resort.
* Surgical procedures include - saphenous vein inversion, high saphenous ligation, ambulatory phlebectomy, transilluminated powered phlebectomy, venous ligation, and perforator ligation.
97
What are the methods of ablation for lower extremity chronic venous insufficiency disease?
* thermal ablation with laser
* radiorequency ablation
* endovenous laser ablation
* sclerotherapy
98
What are the indications for ablation for lower extremity chronic venous insufficiency disease?
* venous hemorrhage
* thrombophebitis
* symptomatic venous reflux
99
What are the contraindications for ablation for lower extremity chronic venous insufficiency disease?
* pregnancy
* thrombosis
* PAD
* limited mobility
* congenital venous abnormalities
