Vascular surgeries Flashcards
Describe etiology and pathophysiology of peripheral artery disease (PAD).
thickening of artery walls leads to progressive narrowing of arteries of the upper and lower extremities.
Affects arteries alone and damages tissues of vessel walls.
Tissue damage is caused by accumulation of fat =atherosclerosis
Atherosclerosis in abd and lower extremities
Arterial disease may occur suddenly, following an embolus, or thrombus, or insidiously as in atherosclerosis.
-most common- thrombus from the heart
assessments for PAD
Health hx & physical exam
Angiography
-inj dye + xray
Ankle-brachial Index (ABI)
-highest ankle SBP / highest arm SBP
-normal: >1. leg BP higher than arm
-People with PVD: <1 (0.8-1 is mild)(0.5-0.8 mod)(<0.5 severe)
decreases with exercise
Doppler ultrasound studies
Describe the clinical manifestations, collaborative care, surgical, and nursing management of the lower extremities in PAD.
Clinical symptoms occur when vessels are 60-70% occluded.
S/s
When symptomatic ⇨ intermittent claudication (exertional related) – classic Sx
Claudication: Pain in thigh or buttocks when you walk (exertional related), as disease progresses, pain at rest often in toes, and worse at night
smooth, shiny, hairless skin in lower extremities; ↓ or delayed distal pulses
Numbness and tingling
Pain or cramping in legs (musclescalf, thigh, or buttocks) during activityand disappears at rest
Slow healing or non-healing sores on toes,feet, or legs
Poor nail growth
*Some people do not experience ANY symptoms
Management:
- Risk factor modification
-DM, HTN, cholesterol, smoking - Drug therapy
-Antiplatelet agents, e.g., ASA (ASA + Plavix together NOT recommended)
-Pentoxifylline (Trental) – for intermittent claudication - Exercise: cessation of smoking combined with supervised exercise
- Nutritional therapy to lower BMI
- Complementary & alternative therapy
-vitamin, mineral, herb supplements →but current research data insufficient
Differentiate the pathology, clinical manifestations, collaborative, and nursing care of different types of aortic dissection.
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Acute arterial ischemia (AAI)
Sudden interruption of blood flow to tissue, organ, or extremity that, if left untreated, would result in tissue death
-Caused by embolism, thrombosis of a pre-existing atherosclerotic artery, or trauma
-left-sided heart thrombus affects lower extremities by occluding iliofemoral, popliteal, tibial arteries
6 P’s
pain- most often in foot or toes, aggravated by movement
pallor - dt elevation
paralysis
paraesthesia- numb, tingling
pulselessness
poikiothermia
Plan appropriate nursing interventions for the patient with acute arterial ischemic disorders.
endovascular procedures x4
or
sx bypasses
Surgical management:
Critical limb ischemia- characterized by chronic ischemic rest pain lasting > 2 wks, arterial leg ulcers, or gangrene of the leg as a result of PAD (peripheral arterial disease)
Optimal therapy is
- Endovascular procedure
OR
-Surgery - for revascularization & to ↓ CVD event
Endovascular procedures x4:
- Percutaneous Transluminal Angioplasty (PTA)
-to restore blood flow with the use of a balloon-mounted catheter, the tip is advanced to where the stenosis is and inflated - Stents
-Deployment of expandable metallic devices within the artery immediately after PTA
-To treat peripheral artery dissection (tear inner arterial wall) - Atherectomy
-removal of obstructing plaque with a high-speed cutting disc built into catheter end - Cryoplasty
-2 procedures: balloon angioplasty + cold therapy
-The specialized balloon inflated with nitrous oxide that changes from liquid to gas as it enters the balloon & ↓ temp of gas to -10 ºC. The cold temp minimizes restenosis
SX
-Aorto-bifemoral Graft
-Bypass extends from distal aorta to common
femoral arteries.
-For stenosis of aorta or iliac vessels.
-Femoro-popliteal Bypass
-Femoro-distal Bypass
-Axillo-bifemoral Graft
-Femoro-femoral Crossover Graft
-
Post-Op Care following
Peripheral Bypass Surgery
immediate care:
-Primary responsibility → early recognition of complications
ABC
VS
-as per protocol
√ peripheral pulses q1h: dorsalis pedis, posterior tibial using a doppler
-Mark the location
-Loss of pulses, or sudden ↑ of pain should be
reported immediately
-could mean a graft occlusion
CWMS
-report sudden changes
-Use a bed-cradle to aid observation, and protect
heels
Observe wound for bleeding or hematoma formation
-Sudden ↑ in output in drainage tube → rupture of
graft anastomosis
-Where graft comes together to artery could
rupture – surgical emergency
*Any indication of graft occlusion or rupture → surgical emergency
Analgesia for pain (i.e., epidural, or a PCA )
-for 24-48hs or until can take them orally
Preventative Abx – in case of graft infection
CVS:
Sit upright, DB & C, gentle leg exercise to prevent chest infection and DVT
-Mobility encouraged 1-2 days post-op
-Elevate legs to prevent occlusion of grafts behind
knee (i.e. femoral to below-knee popliteal graft)
SC HEPARIN- to decrease risk of DVT
NO compression stockings – they put pressure and could occlude vessels. Not for ABI <0.7
Monitor U/O
-should be 30 cc/hr
IV fluids via central line (i.e. CVP line)
sliding scale insulin for diabetic patients
O2 as prescribed
Possibility of paralytic ileus in pts with aortic grafts
-stomach should be empty & N/G
-Func not mechanical
Inspect wounds for signs of inflammation (infection)
Sutures removed 12-14 days post-op
Drainage tubes
Differentiate the pathology, clinical manifestations, collaborative, and nursing care of different types of aortic aneurysms.
Aortic Aneurysms
Aortic Aneurysms
A permanent, localized outpouching, or dilation of vessel wall (congenital or acquired).
May involve aortic arch, thoracic aorta, abdominal aorta, or a combination.
-Most are abdominal aorta below renal arteries.
Dilated aortic wall becomes lined with thrombi.
Could break off = emboli
causes:
-Most common: arth plaque
-Degenerative
-Congenital
-Ehlers Denholm syndrome – collagen defects
-Marfan syndrome – breakdown of elastic tissue
HUGE RISK
-Mechanical
-Inflammatory
-Giant cell arthritis – inflamm of lining or arteries
-infectious
-HIV, syphilis, salmonella
Aneurysms are classified as TRUE or FALSE
TRUE A: the wall of the artery forms the aneurysm, and at least one vessel layer is intact
two types of true A’s
- fusiform aneurysm
-shape bulges or balloons out on all sides of the blood vessel
-common in abd - saccular aneurysm
-shape bulges or balloons out only on one side
-common in brain
-more prone to rupture
FALSE A: aka pseudoaneurysm)
not an aneurysm but a disruption of all layers of arterial wall → results inbleeding that is contained
– may result from trauma or infection, or at the site of peripheral artery bypass surgery
Clinical manifestations: IMPORTANT TO KNOW
-Often asymptomatic
-common:
Thoracic aneurysm ⇨ deep diffuse chest pain extending to interscapular area
Ascending aorta & aortic arch anneurysm
-angina, TIA, hoarseness, coughing, SOB dt pressure on laryngeal nerve
Abdominal A A ⇨ often asymptomatic, detected on routine physical exam
-pulsatile mass in periumbilical area slightly left of the midline- will feel pulse
-back pain caused by compression on lumbar nerve &
epigastric discomfort
Complications:
-Serious: rupture of aneurysm. Emergency. If not tx, death.
-Flank ecchymosis (Grey Turner’s sign)
-Grey turner sign : purple/grey on lower abd wall/flank
-Cullen’s sign. Superficial edema with bruising around umbilical = hemorrhage
-Both appear 24-48 hr after onset of retroperitoneal bleeding
-If blood leaks into retroperitoneal space, bleeding might be contained by surrounding structures. If leaks into thoracic or abd cavity = mortality 90%
Treatment: IMPORTANT TO KNOW
-Goal: to prevent aneurysm rupture and extension of dissection
Conservative therapy is for…
-Small, asymptomatic AAAs (4.0 - 5.5cm)
-Size of aneurysm will determine the risk of rupture
-quit smoking
-tx HTN with meds
-reg U/S q6m with referral to sx if diameter reaches 5.5 cm or grows >1cm in 1 year
SX is recommended for…
-symptomatic or >5.5 cm
-Rapid expanding aneurysm (> 1 cm diameter /year)
-High risk of rupture!!!
tx Involves replacing abdominal aneurysm with a synthetic tube graft
Surgery:
Elective Sx:
-During pre-op:
-Hydration
-Correction of electrolytes, coagulation, hematocrit abnormalities
-Bowel prep
Lower hematocrit have higher blood loss during sx= need fluid/ blood replacement
Procedure:
Incision of diseased aortic segment
Removal of thrombus or plaque
deployment & suturing of synthetic graft
Most resections done in 30 – 45 min
Requires cross-clamp clamping distal to aneurysm
Emergency Sx:
-Ruptured aneurysm ⇨ 100% fatality without emergency surgery
-lethal complication intra op - Intrabdominal HTN withassociated compartmental syndrome
-reduces bloodflow to the viscera = impaired
organ perfusion = multi system organ failure
Post-op careAbdominal Aortic Aneurysm
IMPORTANT TO KNOW
Assess graft patency
-Adequate BP important - prolonged hypertension results in graft thrombosis
-graft thrombosis, stress on anastomosis site,
might burst (where graft attaches to vessel) =
reduce fluid volume = IV diuretic, antiHTN
How to determine ad flow : urine output should be 30 cc/hr
and
MAP: 2(DBP) + SBP / 3 = MAP. MAP should be 65+mmHg. Reflects organ perfusion
——————————————————————————
CVS:
-Continuous ECG monitoring
-Myocardial ischemia or MI during peri-op dt
↓myocardial O2 supply or ↑ demand
-Dysrhythmia dt electrolyte imbalance,
hypoxemia, hypothermia, or myocardial
ischemia
-Electrolyte and ABG monitoring
-Admin O2
-Adequate pain control
-Resume cardiac meds
GI:
After abdominal aortic surgery, paralytic ileus is possible D/T anaesthesia & manipulation of bowel
-Intestines become swollen & bruised, paused
peristalsis
N/G ⇨ _prevent aspiration of stomach content. On low intermittent suction to decompress the bowel
Return of bowel func: listen to bowel sounds, full min in each quadrant. Passing flatus.
Infection:
Vascular graft infection
-Admin broad spectrum antibiotic per order
Assess surgical site for infection
Fever
Increase WBC
Redness, swelling, drainage
Examine IV site and foley cath for infection
CNS:
Assess LOC
Glasgow coma scale
-Highest is 15. lowest is 3. eye, verbal, motor response
With involvement of descending aorta, neurovascular assessment of lower extremities is important
Peripheral perfusion status:
-Check all peripheral pulses q1h for several hrs (or per protocol) and then per routine
-ascending aorta & aortic arch sx= emphasis is to assess temporal, carotid and radial pulses
-descending aorta sx= assess femoral, popliteal, posterior tibial and dorsalis pedis pulses
Renal:
Monitor renal perfusion
Foley cath
Immediate post-op: record U/O q1h maintain 0.5–1 ml/kg/hr
1-1.5 ml/kg/hr urine output ??? wh8ich one
Egfr, BUN, creatinine
I & O, daily weight until resumes regular diet
Factors for low renal perfusion:
-embolization to renal artery(ies)
-Individuals at high risk for renal failure include patients with hypotension, prolonged clamping during surgery, preexisting renal disease or diabetes
Aortic Dissection
having an aortic aneurysm = risk of tear in aortic lining = dissection
Dissection results from creation of a false lumen
Def: Is a tear in aortic intima through which blood enters and creates a false lumen between the intima and media layer of blood vessel
-degeneration of elastic fibers =weak spot
Most common disposing factors:
-HTN
-Marfan’s syndrome- tall and skinny people
-men > women
-age, aortic diseases, atherosclerosis, blunt trauma, tobacco, cocaine or methamphetamine, CHD (congenital bicuspid aortic valve), connective tissue disorders (e.g., Marfan’s syndrome), family history, etc.
Classification based on:
-Anatomical location- ascending or descending
-Duration of onset - acute or chronic
*60-70% of aortic dissection involve ascending aorta & are acute in onset
*Chronic dissection → almost always involve descending aorta
Type A:
-Originate in ascending aorta, usually within a few cm of aortic valve, and either
AI -Extend into descending aorta (TYPE I), or
AII -Limited to ascending aorta (TYPE II)
Type B/type III:
-Involve only descending aorta; begins farther down aorta (beyond the arch), and extends into abdominal aorta.
Clinical manifestations:
Acute ASCENDING aortic dissection
-Sudden, severe, excruciating chest pain, back pain, or both, radiating to neck or shoulders – “sharp”, “worst ever”
-usually causes some degree of disruption in coronary artery blood flow & aortic valve insufficiency → may
cause angina, MI, etc.
Acute DESCENDING aortic dissection
-pain back, abdomen, or legs
Aortic arch
-May show neurological deficit e.g., altered LOC, weakened or absence of carotid to temporal pulses, dizziness, syncope
Management:
-Aortic dissection is medical emergency!
=Once diagnosis of aortic dissection is suspected, treatment should begin immediately.
TYPE A (higher up):
-high mortality
-Requires surgery ⇒ involves replacement with a synthetic graft
TYPE B (only involve descending aorta)
-best managed medically
-1st line of treatment -management of hypertension with IV β-blockers
– goal is to rapidly ↓SBP, pulse pressure, and HR to minimize stress of dissection
– surgery is considered only if complications exist (i.e. rupture, renal or limb ischemia, uncontrollable hypertension, etc.
Post-op care: same as aortic aneurysm repair
