Vascular diseases Flashcards
Exam 4 content
What are the three main arterial pathologies?
- aneurysms
- dissections
- occlusions
What is an aortic aneurysm?
Dilation of all 3 layers of the artery with >50% increase in diameter.
When is surgery indicated for aortic aneurysm?
- > 5.5 cm diameter
- growth of >10mm/year
- family hx of dissection
What is the mainstay surgical treatment for aortic aneurysms?
endovascular stent repair
What are the 2 types of aortic aneurysms?
- Saccular (outpouching on one side)
- Fusiform (circumferential dilation)
What are the symptoms of an aortic aneurysm?
usually asymptomatic unless aneurysm is compressing surrounding structures
If aortic dissection is suspected what is the fastest/safest diagnostic tool? (unstable)
doppler echocardiogram
What are the treatments of aortic aneurysms?
manage BP, cholesterol and smoking cessation, avoid strenuous exercise, stimulants and stress
What is an aortic dissection?
a tear in the intimal layer of the vessel causing blood to enter the medial layer
What are the symptoms of aortic dissection?
severe sharp pain in posterior chest or back
What is Stanford class A and class B for aortic dissections?
A- ascending
B- no ascending component
What are the Debakey class 1,2, and 3 classifications of aortic dissection?
1: ascending and descending component
2: ascending aorta
3: descending aorta
Which classifications involve the ascending aorta?
Stanford A
Debakey 1 and 2
if the ascending aorta is involved, what is the treatment for a dissection?
surgery- ascending aorta and aortic valve replacement or resuspension
What is significant about aortic arch involvement with aortic dissection?
surgical resection is indicated, which requires cardiopulmonary bypass, hypothermia and circ arrest. Neurological deficits are seen in 3-18% of patients
What is different about the management of a Stanford B dissection?
If stable hemodynamics, no hematoma and no branch involvement, treated medically
-intraarterial monitoring of SBP and UOP
-BBs, cardene, sodium nitroprusside
When is surgery indicated for type B dissections?
signs of impending rupture (persistent pain, hypotension and left-sided hemothorax, or compromised perfusion to lower extremity)
What are some of the risk factors for aortic dissections?
HTN, atherosclerosis, aneurysms, family history, cocaine use and inflammatory diseases
Which inherited disorders are commonly associated with aortic dissections?
Marfans, Ehlers Danlos, bicuspid aortic valve
What can acutely cause aortic dissections?
blunt trauma, cocaine, iatrogenic (cardiac cath, aortic manipulation, cross-clamping, arterial incision)
Which two populations are aortic dissections most common?
- men
- pregnant women in their 3rd trimester
What is the triad of symptoms seen in aneurysm rupture?
- hypotension
- back pain
- pulsatile abdominal mass
Where do most abdominal aortic aneurysms rupture?
into the left retroperitoneum
If retroperitoneal tamponade occurs what special precaution should you take?
delay volume resuscitation until the rupture is surgically controlled
What are the 4 primary causes of mortality r/t thoracic aorta surgeries?
- MI
- Resp failure
- Renal failure
- Stroke
What are some preop evaluations used to help define risk of post aortic surgery resp failure?
- PFTs
- ABG
- optimize pulmonary function via bronchodilators, abx, and chest physiotherapy
What preop findings may preclude a patient from aortic resection?
Low FEV1 or renal failure
What pretreatment can you do to minimize renal dysfunction post aortic surgery?
preop hydration and avoid nephrotoxic drugs if possible
If the patient receiving aortic surgery has a history of stroke or TIA, what diagnostic might be warranted?
carotid US or angiogram
What is anterior spinal artery syndrome? And what is significant about ASA?
Lack of blood flow to the arterial spinal artery, which perfuses 2/3 of the spinal cord and lacks collateral flow can cause spinal cord ischemia
What are some symptoms of anterior spinal artery syndrome?
- loss of motor function below infarct
- diminished pain and sensation below infarct
- autonomic dysfunction leading to hypotension and bowel and bladder dysfunction
What are some common causes of anterior spinal artery syndrome?
- aortic aneurysms
- aortic dissection
- atherosclerosis
- trauma
The AHA recommends TPA within___ of symptom onset for CVAs
4.5 hours
when is a carotid endarterectomy indicated?
with severe carotid stenosis
>70% blockage
lumen diameter of 1.5mm or less
Why is carotid stenting no longer ideal for treatment of carotid stenosis?
there is a major risk of microembolization which can lead to a CVA
What are some medical therapies used to manage CVAs?
antiplatelets, BP control, cholesterol management, diet and smoking cessation
What are some preop considerations for patients undergoing carotid endarterectomy?
-establish preop deficits
-CAD? risk of MI
-Maintain BP on the high end of normal
-monitor cerebral oximetry (extreme head rotation during procedure can compress contralateral artery flow)
What are some things that can affect cerebral oximetry?
MAP
CO
SaO2
Hgb
PaCO2
temperature
anesthesia depth
What are a few clinical findings of PAD?
ABI < 0.9
compromised blood flow to extremities
3-5X greater risk of MI or CVA
What are some risk factors of PAD?
advanced age
family history
smoking
DM
HTN
obesity
hyperlipidemia
What are some signs and symptoms of PAD?
intermittent claudication
resting extremity pain
weak pulses
subcutaneous atrophy
hair loss
coolness
cyanosis
What causes relief for pain with patients who have PAD?
hanging leg over side of bed or dangling leg increases hydrostatic pressure
What diagnostic is used to confirm PAD?
doppler US or duplex US
can also get an MRI w/ contrast angiography
What is the medical treatment for PAD and when is surgical revascularization indicated?
medical: exercise, controlling BP, cholesterol and glucose
surgery: w/ disabling claudication and ischemia
What two surgeries are offered for revascularization of PAD?
- surgical reconstruction via bypass
- angioplasty or stent placement
What are the two most common causes of acute peripheral artery occlusion?
Left atrial thrombus d/t afib
Left ventricular thrombus d/t cardiomyopathy post MI
What are some signs of acute peripheral artery occlusion?
limb ischemia, pain, paresthesia, weakness, decreased peripheral pulses, cool skin, color changes distal to occlusion
How are peripheral artery occlusions diagnosed? Treated?
Dx: arteriogram
Tx: anticoagulation, embolectomy, amputation
What is subclavian steal syndrome?
occurs when the SCA is occluded proximal to the vertebral artery. VA flow diverts from the brainstem to the upper portion of the SCA distal to the occlusion
What symptoms are typically seen with subclavian steal syndrome?
syncope, vertigo, ataxia, hemiplegia and ipsilateral arm ischemia
SBP on effected side may be 20mmHg lower
Bruit over SCA
What are some of the risk factors of subclavian steal syndrome?
atherosclerosis
h/o aortic surgery
Takayasu arteritis
What is the treatment for subclavian steal syndrome?
subclavian endarterectomy
What is Raynaud’s phenomenon?
episodic vasospastic ischemia of the digit. Digital cyanosis or blanching with cold exposure or SNS activation
Who does Raynaud’s phenomenon effect more?
Women > men
What are some treatment options for Raynaud’s?
protection from cold, CCB’s, alpha-blockers
what are three common PVD processes that occur during surgery?
- superficial thrombophlebitis
- DVT
- chronic venous insufficiency
What is Virchow’s triad?
- venous stasis
- disrupted vascular endothelium
- hypercoagulability
with which surgical procedure are DVT’s most common?
total hip replacements
What are some risk factors for DVT’s?
age >40
surgery >1hr
cancer
ortho procedures on pelvis and LE’s
abdominal surgery
What are some prophylactic measures we can take to prevent DVT’s?
all surgical patients should receive SCD’s
SQ heparin for patients at high risk
How do we treat DVT’s?
anticoagulation (warfarin, heparin or LMWH)
bridge from heparin to warfarin
INR of 2-3
PO anticoagulants are continued for 6+ months
IVC filter may be indicated if recurrent PE
what is systemic vasculitis?
a group of inflammatory diseases categorized by the size of the vessels
What are two large artery vasculitis disorders?
- Takayasu arteritis
- Temporal or giant cell arteritis
What is an example of a disorder that causes medium artery vasculitis?
Kawasaki disease which usually affects the coronary arteries
What are three examples of disorders that cause small artery vasculitis?
- Thromboangiitis obliterans
- Wegener granulomatosis
- Polyarteritis nodosa
What is temporal or giant cell arteritis and what are some common symptoms?
inflammation of the arteries of the head and neck.
sx: unilateral HA, scalp tenderness and jaw claudication, may cause unilateral blindness
What is used to diagnose giant cell arteritis? To treat it?
Dx: biopsy
Tx: corticosteroids
What is thromboangiitis obliterans or “Buerger disease”?
autoimmune response triggered by nicotine that causes inflammatory vasculitis leading to small and medium vessel occlusions in the extremities
What are the 5 diagnostic criteria for thromboangiitis obliterans?
h/o smoking
onset before 50
infrapopliteal arterial occlusive disease
upper limb involvement
absence of risk factors for atherosclerosis
What are some symptoms of thromboangiitis obliterans?
forearm, calf and foot claudication
ischemia of hands and feet
ulceration
Raynaud’s
What is the treatment for thromboangiitis obliterans?
smoking cessation
surgical revascularization
what are some anesthesia considerations for patients with small vessel vasculitis?
avoid cold, keep limbs warm
meticulous padding and positioning to maintain blood flow
conservative line placement
What is Polyarteritis Nodosa?
Vasculitis of the small and medium vessels.
Often leads to glomerulonephritis, MI, peripheral neuropathy and seizures.
What is Polyarteritis Nodosa commonly associated with?
Hep B, Hep C or hairy cell leukemia
HTN caused by renal disease
renal failure
How is polyarteritis nodosa treated?
Steroids, cyclophosphamide, treat underlying cause (cancer)
Name some risk factors for lower extremity chronic venous disease…
advanced age, family hx, pregnancy, previous VT, LE injuries, prolonged standing, obesity, smoking, sedentary lifestyle, high estrogen levels
What are a few mild symptoms and more severe symptoms of LE chronic venous disease?
mild sx: telangiectasias, varicose veins
severe sx: edema, skin changes and ulcerations
How is LE chronic venous disease diagnosed?
leg pain, heaviness, fatigue
Dx w/ US showing retrograde blood flow >0.5s
What are some treatment options for LE chronic venous insufficiency?
leg elevation, exercise, weight loss, compression therapy, skin barrier cream, steroids, wound management
What are some medications used for conservative medical management of LE venous insufficiency?
diuretics, aspirin, abx, prostacyclin analogues, zinc sulphate
What surgical interventions are available for LE chronic venous disease?
saphenous vein inversion
ablation
high saphenous ligation
ambulatory phlebectomy
transilluminated-powered phlebectomy
venous ligation
perforator ligation
