Vascular Diseases Flashcards
Test 4
What are the three main arterial pathology?
Aneurysms
Dissections
Occlusions
The aorta and its branches are more likely to experience _________. Why?
Aneurysms & dissections
This is dt them being high flow vessels
The peripheral arteries are more likely to be affected by ________. Why?
Occlusions
This bc they are smaller
How is an aortic aneurysm defined?
Dilation of all three layers of the artery –> >50% increase in diameter
Sx is indicated for an aortic aneurysm when it reaches _____ in diameter
> 5.5 cm
Rupture of an aortic aneurysm is associated with a _____ mortality rate
75%
What are the two types of aneurysms? Describe them.
Saccular: bulge to one side
Fusiform: uniform circumferential dilation
What do you use to Dx in aortic aneurysm? Suspected dissection?
CT, MRI, CXR, angiogram, echo
Suspected dissection: echo/TEE is fastest/safest
A dessetion is a _______ in the intimal layer. What does this cause?
Dissection = tear
Blood to enter medial layer –> aneurysm
T/F: Ascending dissections are catastrophic and require emergent surgical intervention
T
What is the hallmark sign of an ascending aortic dissection?
Severe sharp pain in posterior chest or back
Mortality increases by ____% per hour with ascending dissection without treatment. What is the overall mortality?
1-2%
27-58%
What is Stanford Type A Dissection? Tx?
Involves both ascending & descending aorta or just the ascending only
candidate for Sx dt arch involvement
Tx: resection w/ ascending aorta & aorta valve replacement w/a composite graft or resuspension of the aortic valve
What does aortic resection involve? What consideration should we have?
Cardiopulmonary bypass
A period of profound hypothermia (15-18C) during circulatory arrest for 30-40 minutes
Considerations: Neuro deficits seen in 3-18% of pts
What is Stanford Type B Dissection? Tx?
Involves descending aorta only
With normal hemodynamics, no hematoma, no branch involvement
Tx: Medically treated
-Art-line: Close SBP monitoring
-Monitor UO
-Control BB & LV contraction (BB, Cardene, Nitroprusside)
T/F: surgery is never indicated for Stanford type B dissection
F
Surgery is indicated w signs of impending rupture: persistent, posterior back pain, hypertension, L hemothorax
What are the risk factors associated with aortic dissection?
HTN
Atherosclerosis
Previous aneurysms
Family history
Cocaine use
Inflammatory disease diseases
What are inherited/genetic disorders that increase the risk of in aortic dissection?
Marfans
Ehlers Danlos
Bicuspid Aortic Valve
What are causes of an aortic dissection?
Blunt trauma
Cocaine use
Iatrogenic:
-cardiac catheterization
-aortic manipulation
-cross clamping
-arterial incision
Aortic dissection are more common in ______ (2)
Men
Pregnant women in 3rd trimester
What does iatrogenic mean?
Caused by medical tx
What is the triad of symptoms seen with aneurysm rupture?
Hypotension
Back pain
Pulsatile abdominal mass
Most abdominal aortic aneurysms rupture into the _________
Left retroperitoneum
What prevents hypovolemic shock with an aortic aneurysm rupture? What consideration should we have?
Clotting & tamponade and the retroperitoneum
If this occurs, delay volume resuscitation until the rupture is surgically repaired.
Volume resuscitation can dislodge the clot –> further the bleeding –> death
Maintaining a lower BP = reduces this risk
What are the four primary causes of mortality r/t surgeries of the thoracic aorta?
MI
Respiratory failure
Renal failure
Stroke
What are preop considerations we should have with aortic aneurysms?
-assess for presence of CAD, valve dysfunction, HF
-Cardiac evaluation test: stress test, echo
-Hydrate preop
-hx of stroke? –> carotid ultrasound & angiogram of brachiocephalic & intracranial arteries
-severe carotid stenosis? –> workup for CEA beofre elective Sx
________ may require intervention prior to surgery with aortic aneurysms
Ischemic heart disease
__________ (2) may preclude a patient from aortic resection. Why?
Low FEV1
Renal failure
They don’t have good outcomes
What is a predictor of post aortic surgery respiratory failure? What helps to find these risks? What can we consider doing to help improve risks?
Smoking
COPD
PFT & ABGs
Bronchodilators
abx
Chest physiotherapy
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 _____ of the ______
2/3
Spinal cord
Ischemia to the anterior spinal artery (ASA syndrome) can cause what type of symptoms?
- loss of motor function
- diminished pain and temperature
- anatomic dysfunction (hypotension, bowel, bladder)
________ is the most common form of spinal cord ischemia. Why?
Anterior spinal artery (ASA syndrome)
Has minimal collateral perfusion
What causes anterior spinal artery syndrome (ASA syndrome)?
Aortic aneurysms
-aortic dissection
-artherosclerosis
-trauma
What are the modifiable risk factors for cerebral vascular accidents (CVA)?
Elevated BP
Smoking
DM
CAD
A fib
HF
High cholesterol
Obesity or physical inactivity
What are the inherited risk factors for cerebral vascular accidents (CVA)?
Age
Prior history of stroke
Family history of stroke
Being black
Being male
Sickle cell disease
CVA is defined as a _________
Sudden onset of neurological deficits
_______ is a prominent predictor of CVA
Carotid disease
What are the diagnostic testings for carotid disease? (5) How does each one differ?
Angiography: vascular occlusions
CT/MRI: less invasive; identify aneurysms, and AVMs
Transcranial Doppler US: vascular occlusions with real time monitoring
Carotid auscultation: bruits
Carotid US: quantify degree of stenosis
Carotid stenosis commonly occurs at the _________. Why?
Carotid bifurcation
Turbulent blood flow at the branch point
TPA is to be administered within _____ of onset of symptoms
4.5 hours
What are treatments of CVA? (4) What considerations should we have?
-IR: intra-arterial thrombolysis
-Intravascular thrombectomy
Carotid Endarterectomy (CEA): lumen diameter 1.5mm or >70% blocked
Carotid stenting: Major risk of microembolization –> CVA
What are medical treatments that you will be on after CVA surgery?
Antiplatelet medication
Smoking cessation
BP medication
Cholesterol medication
Diet & exercise
_____ is a major cause of preoperative mortality in CEA
MI
What are some CEA preop considerations?
Neuro exam
Established acceptable BP to optimize CPP (want on higher side of normal)
Use cerebral oximetry devices (foresight, INVOS) to help trend cerebral perfusion –> extreme head rotation may compress contralateral artery flow
CPP =
MAP - ICP
What is a clinical dilemma commonly seen the CEA surgery?
Severe carotid disease is commonly seen with severe coronary artery disease as well.
Both surgeries would need to happen, the most compromise area should take priority.
One is affecting the heart & the other affecting the brain
Cerebral oxygenation is affected by ____ (5)
MAP
COP
02 sat
Hb
PACO2
Cerebral O2 consumption is affected by ____ (2)
Temperature
Depth of anesthesia
What is peripheral artery disease (PAD)? How was it defined?
Compromise/decreased blood flow to the extremities
Defined: ankle-brachial index (ABI) <0.9
What is ankle-brachial index (ABI)?
Ratio:
Ankle SBP : Brachial artery SBP
What can cause peripheral artery disease?
Artherosclerosis (systemic)
Vasculitis
Embolism (acute)
Pts w/ PAD have a ____x increased risk of MI & CVA
3-5x
What are peripheral artery disease risk factors (PAD)?
Age
Family
Smoking
DM
HTN
Obesity
High cholesterol
What are peripheral artery disease symptoms (PAD)?
Intermittent claudication (pain, cramping, fatigue muscles)
-resting extremity pain
-weak pulses
-subcutaneous atrophy
-hair loss
-coolness of the extremities
-cyanosis
-relief with hanging left extremity over side of bed –> increases hydrostatic pressure
How do you Dx peripheral artery disease (PAD)?
-Doppler/US: identifies arterial stenosis
-Duplex U/S: identifies plaque formation/ calcification
-transcutaneous oxymetry: assess the severity of tissue ischemia
-MRI with contrast angiography: used to God endovascular intervention or surgical bypass
How do you Tx peripheral artery disease (PAD)?
Medical: exercise
Control BP, cholesterol, glucose
Sx: arterial bypass
Endovascular repair: angioplasty or stent placement
ACUTE peripheral artery occlusion is normally due to _____ caused by _______ (2). How do you Dx this? Tx?
Embolism
-L atrial thrombus dt a fib
-L ventricular thrombus dt cardiomyopathy post MI
Dx: Arteriogram
Tx: anticoagulation
Surgical embolectomy
Amputation (last resort if no perfusion & risk of sepsis)
What is Subclavian Steal Syndrome? What does it affect? Symptoms? Risk factors? Tx?
Occluded subclavian artery –> proximal to vertebral artery increased flow –> vertebral artery flow divert away from brain stem
Symptoms: syncope, vertigo, ataxia, hemiplegia, ipsilateral arm ischemia
Effected arm: SBP 20 mmhg lower & bruit
Risk factors: artherosclerosis, previous aortic surgery, takayasu arteritis
Tx: subclavian endarterectomy
What is Raynaud’s Phenomenon? What does it affect? Symptoms? Dx? Tx?
Episodic vasospastic ischemia of the digits (fingers/toes)
Symptoms: Digital blanching, cyanosis with cold exposure or SNS activation
Dx: based on history and physical
Tx: protect from cold
CCB
Alpha blockers
Surgical sympathectomy (severe cases only)
Raynaud’s Phenomenon affects _____ more
women (more than men)
What are common peripheral Venus disease processes that occur during surgery (PVD)? Which is the most concerning? Why?
Superficial thrombophlebitis
Deep vein thrombosis
Chronic venous insufficiency
DVT –> PE –> leading cause of perioperative morbidity and mortality
What is Virchow’s Triad? What is a consist of?
Three factors that predisposed to Venous thrombosis
- Venous stasis
- Disrupted vascular endothelium.
- Hypercoagulation
Which PVD is associated with total hip replacements?
Superficial thrombophlebitis
Deep vein thrombosis
50% of these cases get them. Normally subclinical and resolves
What are risk factors for DVT’s?
> 40 yo
Sx >1 hr
Cancer
Ortho Sx on pelvis/LE
abd Sx
_______ greatly reduces risk of DVT’s dt postop ambulation
Regional anesthesia
What is considered low risk for DVT? What are the recommendations for this?
< 40yo
Sx <60 min
compression stockings
early ambulation
What is considered moderate risk for DVT? What are the recommendations for this?
> 40 yo
sx >60 min
postpartum
MI
CHF
SCD
SQ heparin
IV dextran
What is considered high risk for DVT? What are the recommendations/Tx for this?
> 40yo
sx >60 min
Previous DVT
Previous PE
Extensive trauma
Major fx
Hip/knee replacement
Extensive soft tissue injury
Stroke
SCDs
SQ heparin
IV dextran
IVC filter (w/ recurrent PE or contra to anticoags)
IV heparin –> Warfarin PO (6 months or longer)
What are the pros vs cons for LMWH over UFH?
pros: longer 1/2 life
-more predictable dose responses
-Less risk of bleeding
cons: higher cost
-no reversal (protamine partially works on lovenox)
What is the target INR for DVT with warfarin Tx?
2-3
What is systemic vasculitis? How are they all categorized? (3)
Group of vascular inflammatory disease is categorized by the size of the vessels at the primary side of the abnormality
- Large artery vasculitis:
-Takayasu arteritis
-Temporal (giant cell) arteritis - Medium artery vasculitis:
-Kawasaki disease (coronaries) - Medium-small artery vasculitis:
-Thromboangiitis obliterans
-Wegener granulomatosis
-Polyarteritis nodosa
Describe Temporal (giant cell) arteritis. Symptoms; Dx; Tx
Inflammation of arteries in the head and neck
Symptoms: unilateral; HA; scalp tenderness; jaw, claudication
optic neuritis ischemia –> unilateral blindness dt opthlamic aterial inflammation
Dx: biopsy of temporal artery
Tx: corticosteroids indicated for visual symptoms to prevent blindness
Describe Thromboangiitis Obliterans “Buerger Disease”. What is it triggered by? Symptoms; Dx; Tx
Inflammatory vasculitis leading to small and medium vessel occlusion in the extremities
Autoimmune response
Triggered by nicotine
Symptoms: forearm, calf, foot claudication
Ischemia of hands and feet
Ulceration and skin necrosis
Raynauds
Dx: confirmed with biopsy of vascular lesions
Tx: smoking cessation (most effective)
-Surgical revascularization
no effective pharmacological Tx
In Thromboangiitis Obliterans “Buerger Disease”, it is more common in _____ below the age of _____. What is the predisposing factor?
men
below 45 yo
Tobacco
What is the five diagnostic criteria for Thromboangiitis Obliterans “Buerger Disease”?
- h/o smoking
- Onset before 50.
- Infrapopliteal arterial exclusive disease.
- Upper limb involvement.
- Absence of risk factors for. atherosclerosis
What are anesthesia considerations with Thromboangiitis Obliterans “Buerger Disease”?
Meticulous positioning and padding
-Avoid cold – warm the room and use warming pads
-Prefer non-invasive BP and conservative line placement
What is Polyarteritis Nodosa? What does it affect? associated with? Tx? Considerations?
Vasculitis of the small and medium vessels
Leads to glomerulonephritis, MI, peripheral neuropathy, and seizures
Associated with: Hep B, Hep C, Hairy cell leukemia
Tx: steroids
-cyclophosphamide
-tx underlying cause (if cancer)
Considerations: coexisting diseases
-give stress dose
What is the primary cause of death in Polyarteritis Nodosa?
Renal failure
What is lower extremity chronic venous insufficiency? Symptoms; Dx;
Long-standing venous reflux and dilation
Symptoms:
mild: telangiectasias, varicose veins
Severe: edema, skin changes, ulceration
Dx: symptoms of leg, pain, heaviness, fatigued
confirmed by ultrasound showing retrograde blood flow >0.5secs
What are the risk factors for lower extremity chronic venous insufficiency?
Advance age
Family history
Pregnancy
Ligamentous laicity
Previous venous thrombosis
LE injuries
Prolonged standing
Obesity
Smoking
Sedentary lifestyle
High estrogen levels (birth control)
What is the treatment for lower extremity chronic venous insufficiency?
Initially conservative:
Leg elevation
Exercise
Weight loss
Compression therapy
Skin barriers
Steroids
Weight management
Conservative medical treatment:
Diuretics
Aspirin
Antibiotics
Prostacyclin analogues
Zinc sulphate
Surgical interventions (last resort)
Saphenous vein inversion
High saphenous ligation
Ambulatory phlebectomy
Transilluminated-powered phlebectomy
Venous ligation
Perforator ligation
