Vascular Diseases - Exam 4 Flashcards
1
Q
What are the 3 main arterial pathologies?
A
Aneurysm
Dissections
Occlusions
2
Q
A dilation of all 3 layers of the artery leading to a >50% increase in diameter is a sign of a
A
Aortic Aneurysm
3
Q
Symptoms of an aortic aneurysm are most likely due to
A
Compression of the structures around it
4
Q
What is the initial treatment plan for aortic aneurysms?
A
Medical management
5
Q
Aortic aneurysm rupture is associated with a
A
75% mortality rate
6
Q
What are the 2 types of aortic aneurysms?
A
- Saccular
- Fusiform
7
Q
This type of aortic aneurysm is characterized by an outpouching bulge to one side
A
Saccular
8
Q
This type of aortic aneurysm is characterized by uniform circumferential dilation
A
Fusiform
9
Q
In suspected aortic dissection, what is the fastest/safest measure of obtaining a diagnosis of aneurysm?
A
Doppler Echocardiogram
10
Q
Treatment for aneurysms?
A
Manage BP, cholesterol, stop smoking
No strenuous exercise, stimulants or stress
11
Q
When is surgery indicated for aortic aneurysms?
A
Surgery is indicated at > 5.5 cm in diameter
Growth > 10 mm/year
Family history of dissection
12
Q
What is the mainstay intervention for aortic aneurysms over open surgery with a graft?
A
Endovascular stent repair (need CV surgeon on standby)
13
Q
A tear in the intimal layer of the vessel, causing blood to enter the medial layer is?
A
Aortic dissection
14
Q
Ascending aortic dissections are what classification?
A
Stanford A & Debakey 1 & 2
15
Q
What type of dissection is catastrophic and emergent, requiring emergent surgical intervention
A
Ascending aortic dissection
16
Q
As an ascending dissection grows, mortality rate increases by ____ % per hour without treatment
A
1-2% per hour
17
Q
What is the symtoms of ascending aortic dissection?
A
Sever sharp posterior back or chest pain
18
Q
How can you diagnose a dissection if the patient is stable?
A
CXR, CT, MRI, Angio
19
Q
How can you diagnose a dissection if the patient is Unstable?
A
Echocardiogram
20
Q
Stanford class A includes:
A
Ascending aorta and maybe descending dissection
21
Q
Stanford class B includes:
A
Only descending dissection
22
Q
DeBakey Class 1 includes
A
Ascending arch, and descending dissection
23
Q
DeBakey Class 2 includes:
A
Only ascending dissection
24
Q
Debakey Class 3 includes
A
Only descending dissection
25
Stanford A dissections should be considered for
emergency surgery
26
What are the most common procedures for a Stanford A dissection?
1. Ascending aorta & aortic valve replacement with
composite graft
2. Ascending aorta replacement with resuspension
of the aortic valve
27
If the aortic arch is involved in the dissection, what is indicated?
Surgical resection
28
Surgery for Stanford A (ascending aorta) dissections require what 3 interventions?
1. Cardiopulmonary bypass
2. Profound Hypothermia
3. Period of circulatory arrest
29
What temp, tolerated by most patients is the circulatory arrest for ascending dissection repair?
15-18 C for 30-40 minutes
30
What is a major complication associated with aortic arch replacement surgery?
Neurological deficit (3-18%)
31
This type of dissection with normal hemodynamics, no hematoma, and no branch-vessel involvement can be treated medically
Stanford B (Descending)
32
What is medical therapy for Stanford B (Descending) dissection?
1. Arterial monitoring of SBP and UOP
2. Drugs to decrease BP
3. Drugs to decrease force of LV contraction
(BB, Cardene, SNP)
33
Long term survival rate of Stanford B (Descending) with medical treatment is _____ % at 5 years and _____ % at 10 years
60-80% at 5 years
40-50% at 10 years
34
What are signs of impending descending dissection rupture?
Persistent pain
Hypotension
Left-sided hemothorax
Comprimosed lower body perfusion
35
Which type of dissection is treated with emergency surgery and which type are rarely treated with urgent surgery?
Emergency - Ascending arch
Rarely treated - Descending arch
36
What are risk factors for dissection?
HTN
Atherosclerosis
Aneurysms
Family Hx
Cocaine use
Inflammatory Dx
37
What are inherited disorders putting you at risk for dissecction?
Marfan's
Ehlers Danlos
Bicuspid Aortic Valve
38
What are some causes of disssection?
Blunt trauma
Cocaine
Iatrogenic (medical treatment caused)
39
What are iatrogenic causes of disssection?
Cardiac Cath
Aortic manipulation
Cross-clamping
Arterial Incision
40
What population are dissections most common in?
Men
Pregnant women in 3rd trimester
41
What are the triad of symptoms seen in aortic aneurysm rupture?
1. Hypotension
2. Back pain
3. Pulsatile abdominal mass
42
Most abdominal aortic aneurysms rupture into which space?
Left Retroperitoneum
43
After an aortic aneurysm ruptures, what can occur that might prevent exsanguination?
Clotting and retroperitoneal tamponade
44
What should be done if retroperitoneal tamponade occurs?
Volume resuscitation should be delayed until the rupture is controlled surgically
-Maintain low BP and reduce risk of bleeding
45
What are 4 primary causes of mortality related to surgeries of the thoracic aorta?
* MI
* Respiratory failure
* Renal failure
* Stroke
46
Ischemic heart disease might require what prior to aortic surgery?
Coronary stenting
47
What tests should be ordered prior to aortic resection?
Cardiac Eval test: Stress, Echo
FEV1/PFT
ABGs
48
What 2 things may preclude a patient from aortic resection?
Low FEV1 and Renal failure (bad outcomes)
49
What is a predictor of post aortic surgery respiratory failure?
Smoking/COPD
-Consider bronchodilators, ABX, and chest physiotherapy
50
What is the most significant indicator of post-aortic surgery renal failure?
Preop Renal Dysfunction
-Preoperatively hydrate, avoid hypovolemia & low CO, avoid nephrotoxins
51
If your patient had a history of stroke and is here for aortic surgery, what testing/imaging should you do?
Cardiac ultrasound
Angiogram of brachiocephalic and intracranial arteries
52
If your patient had a history of severe carotid stenosis and is here for aortic surgery, what should you do?
Workup for CEA before elective surgery
53
What syndrome is caused by a lack of blood flow to the anterior spinal artery?
Anterior Spinal Artery Syndrome (ASA Syndrome)
54
The ASA perfuses the ______ ____ of the spinal cord
Anterior 2/3
55
ASA ischemia leads to:
1. Loss of function below the infarct
2. Diminished pain and temperature below the infarct
3. Autonomic Dysfunction - (Hypotension and bowel/bladder problems)
56
ASA syndrome is the most common form of spinal cord ischemia b/c the ASA has minimal ...?
collateral perfusion
57
How many arteries is the posterior spinal cord perfused by?
2 arteries
58
What are 4 causes of ASA syndrome?
1. Aortic aneurysm
2. Aortic Dissection
3. Atherosclerosis
4. Trauma
59
What is a prominent predictor of CVA?
Carotid Disease
60
CVA is the 1st leading cause of ______ and 3rd leading cause of ______
1st: Disability
3rd: Death
61
What type of demographic are inherited risk factors of having a stroke?
Men, Sickle cell, african-americans
61
What is temporary, self-limiting ischemia that resolves in 24 hrs and makes someone 10x more likely to have a stroke?
TIA
62
What test can quantify the degree of carotid stenosis
Carotid US
63
What test can diagnose a vascular occlusion (more invasive & less invasive)
Angiography
Less invasive: CT and MRI
64
What test has real time monitoring to give evidence of vascular occlusions
Transcranial Doppler US
65
What test can identify cartoid bruits (turbulent flow)
Carotid auscultation
66
Where is carotid stenosis most likely to develop? And why?
Carotid Bifurcation due to turbulent flow at the branch point
67
Workup for CS includes evaluation of for sources of emboli such as:
A-fib
HF
Valvular Vegetation
68
AHA recommends TPA within ____ hrs of symptom onset of a CVA
4.5 hrs of symptom onset
69
What interventions can be done for CVA (radiology)
1. Intra-arterial thrombolysis
2. Intravascular Thrombectomy
70
What are the time recommendations for thrombectomy?
Benefits seen up to 8 h after CVA onset and should be done within 90 minute window
71
CEA is indicated for carotid stenosis when lumen diameter is _____ mm or > _____ % blockage
CEA when diameter 1.55 mm or > 70% blockage (benefits outweigh risks)
72
This intervention has a major risk of microembolization but is an alternative to CEA
Carotid stenting
73
Ongoing medical therapy for CVA includes:
1. Antiplatelet therapy
2. smoking cessation
3. BP control
4. Cholesterol control
5. Diet and physical therapy
74
What is prevalent in carotid disease?
CAD
75
What is a major cause of perioperative mortality in CEA?
MI
76
HTN is common in CEA patients, what do we want to do with the MAP during surgery?
Keep MAP on the elevated side (CPP = MAP-ICP)
77
What is important in positioning for CEA cases?
Maintain collateral blood flow thru stenotic vessels during cross-clamping
-Extreme head rotation/flexion/extension may compress contralateral artery flow
78
What can we use to gauge and trend cerebral perfusion?
Cerebral oximetry devices (Foresight, INVOS)
79
What do you do if you have severe carotid disease and severe coronary artery diseases?
Stage cardiac revascularization and CEA - the MOST compromised area should take priority
80
Cerebral oxygenation is affected by:
MAP
CO
SaO2
Hgb
PaCO2
81
Cerebral oxygen consumption is affected by: (2)
1. Temperature
2. Depth of anesthesia
82
Peripheral artery disease (compromised blood flow to extremities) is defined by ABI < ___?
ABI < 0.9
83
ABI measures:
SBP at ankle: SBP at Brachial artery
84
Chronic hypoperfusion in PAD is due to:
Atherosclerosis and maybe vasculitis
85
Acute occlusions in PAD is due to :
Embolism
86
Pt. with atherosclerosis have 3-5x increased risk of?
MI and CVA
87
S/S of PAD?
1. Intermittent claudication
2. Resting extremity pain
3. Weak pulses
4. SQ atrophy
5. Hair loss
6. Coolness
7. Cyanosis
88
PAD pt. have relief when doing what?
When hanging LE over the side of the bed (increased hydrostatic pressure)
89
Pain in the back of the legs exacerbated by exercise and walking is
Claudication
90
This test for PAD can provide pulse volume waveform that identifies arterial stenosis
Doppler US
91
This test for PAD identifies areas of plaque formation and calcification
Duplex US
92
This test for PAD assesses severity of tissue ischemia
Transcutaneous oximetry
93
This test for PAD is used to guide endovascular intervention or sx bypass
MRI with contrast angiography
94
What is medical tx for PAD
Exercise
Controlling BP, cholesterol, and glucose
95
What is indicated when PAD pt. have disabling claudication or ischemia?
Surgical Repair - Arterial bypass
Endovascular Repair - Angioplasty or stent placement
96
Common causes of acute peripheral artery occlusion are (2)
1. LA thrombus d/t A-Fib
2. LV Thrombus due to cardiomyopathy after MI
97
Sublcavian steal syndrome is characterized by:
Occluded Subclavian artery proximal to the vertebral artery
98
S/s of subclavian steal syndrome?
Syncope, Vertigo, Ataxia, hemiplegia and ipsilateral arm ischemia
99
If you have right SC steal syndrome, the ____ arm will have SBP ____ mmHg lower
Right arm; 20 mmHg lower
100
Risk factors for SC steal syndrome?
Atherosclerosis, History of aortic surgery, Takayasu Arteritis
101
Treatment for SC steal syndrome?
Subclavian Endarterectomy
102
Episodic vasospasm ischemia causing digital blanching or cyanosis with cold exposure of the digits is what? Does it affect men or women more?
What NS does it activate?
Raynaud's phenomenon affects women - SNS activation
103
Treatment for Raynauds?
Protection from cold
CCB
Alpha-blockers
Surgical sympathectomy for severe ischemia
104
What are 3 common PVD processes during surgery?
1. Superficial thrombophlebitis
2. DVT
3. Chronic venous insufficiency
105
What is a major concern with PVD?
DVT leading to PE
106
What is Virchow's triad?
3 Factors that predispose to venous thrombosis
-Venous stasis
-Disrupted vascular endothelium
-Hypercoagulability
107
Superficial thrombophlebitis and DVT are common in surgery, occurring in ____ % of total hip replacements
50% - normally resolves/subclinical
108
Risk factors for DVT?
1. Age > 40
2. Surgery over 1 hour
3. Cancer
4. Ortho surgery on pelvis and LE
5. Abdominal surgery
109
What are prophylactic intervention for DVT?
1. compression stocking
2. SCD
3. SQ heparin 2-3x per day
110
Regional anesthesia has a decreased risk of DVT due to
early post-op ambulation
111
Low risk for DVT is
Age < 40 and Surgery < 1 hour
Medical condition: Pregnancy
112
Moderate DVT risk is
Age > 40 and surgery > 1 hour
Medical condition: Post-Partum
113
High risk for DVT is
Age > 40, Surgery > 1 hour, previous DVT or PE, Trauma, major fractures
Medical condition: Stroke
114
What is anticoagulation tx for DVT?
Warfarin + Heparin or LMWH
115
What are LMWH advantages over unfractionated heparin?
1. Longer half-life
2. More predictable dose-response
3. No serial aPTT assessment
4. Less bleeding risk
116
Disadvantages of LMWH?
1. Higher Cost
2. Lack of Reversal agent
117
______ is initiated during heparin treatment and adjusted to achieve INR between ______
Warfarin; INR between 2-3
118
What is indicated with recurrent PE or contraindication to Anti-coagulants?
IVC filter
119
How long are PO anticoagulants continued for DVT?
6 months or longer
120
Vascular inflammatory diseases categorized by the size of vessels at the primary site of abnormality is what?
Systemic Vasculitis
121
Large-artery Vasculitis includes
1. Takayasu Arteritis
2. Temporal (giant cell) Arteritis
122
Medium-artery Vasculitis includes
Kawasaki disease (coronary arteries)
123
Medium-small artery Vasculitis includes
1. Thromboangiitis Obliterans
2. Wegener Granulomatosis
3. Polyarteritis Nodosa
124
This type of vasculitis is caused by inflammation of the arteries in the had and neck and affects people > 50 years old
Temporal (giant cell) Arteritis
125
S/s of Temporal arteritis include
Unilateral: Headache, scalp tenderness, jaw claudication
126
In temporal arteritis, opthalmic arterial branches might lead to
ischemic optic neuritis
unilateral blindness
127
Temporal arteritis diagnosis is done with
Biopsy
128
Treatment for Temporal arteritis
Corticosteroids for visual symptoms and to prevent blindness (might need stress-dosing)
129
This vasculitis is characterized by inflammatory small and medium vessel occlusions in the extremeties
Thromboangiitis Obliterans "Buerger Disease"
130
Thromboangiitis Obliterals is an autoimmune response triggered by ____ with ____ use being the most predisposing factor in men < 45 years
Nicotine; Tobacco
131
5 diagnostic criteria for Thromboangiitis Obliterals
1. Hx of smoking
2. Onset before 50
3. Infrapopliteal arterial occlusive disease
4. Upper limb involvement
5. Absence of risk factors for atherosclerosis
132
S/s of Thromboangiitis Obliterals
* forearm, calf, foot claudication
* Ischemia of hands & feet
* Ulceration and skin necrosis
* Raynaud's is commonly seen
133
What is the most effecctive treatment to reestablish perfusion in the vessels during Thromboangiitis Obliterals
Smoking cessation (there is no pharm. treatment, only surgical revascularization)
134
Anesthesia implications for Thromboangiitis Obliterals?
Meticulous positioning/padding, avoid cold, NIBP over A-line
135
Vasculitis of the small/medium vessels leading to glomerulonephritis, MI, peripheral neuropathy and seizures is?
Polyarteritis Nodosa
136
Polyarteritis Nodosa may be associates with (3)
1. Hep B & C or Hairy cell leukemia
137
What is the primary cause of death in Polyarteritis Nodosa
Renal failure (HTN is caused by this)
138
Treatment for Polyarteritis Nodosa?
Steroids, cyclophosphamide, underlying cause (CA)
139
Anesthesia implications for Polyarteritis Nodosa
Consider: Renal disease, cardiac disease, HTN
140
Lower extremity chronic venous disease is long standing venous reflux and dilation affecting ____% of the op
50%
141
Mild and severe symptoms of LE chronic venous insufficiency?
Mild: Telangiectasias, Varicose veins
Severe: Edema, skin changes, ulcerations
142
Risk factors for venous insufficiency?
*advanced age
*family hx
*pregnancy
*ligamentous laicity
*previous venous thrombosis
*Lower extremity injuries
*prolonged standing
*obesity
*smoking
*sedentary lifestyle
HIGH ESTROGEN LEVELS (BIRTH CONTROL)
143
Dx criteria for venous insufficiency?
Ultrasound showing venous reflux with retrograde blood flow > 0.5 seconds
144
Symptoms of venous insufficiency?
Leg pain
Heaviness
Fatigue
145
Treatment for venous insufficiency?
Initially conservative
* Leg elevation
* Exercise
* Weight loss
* Compression therapy
* Skin barriers/emollients
* Steroids
* Wound management
146
What is conservative medical treatment for venous insufficiency?
Diuretics
Aspirin
ABX
Prostacyclin analogues
Zinc Sulpate
147
If medical management of venous insufficiency fails, what can be performed?
Ablation, surgery is last resort
