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NURS 412 > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

Peripheral vascular disease

A

broader term that includes any blood vessel encompassing arteries, veins and lymphatic vessels.
doesn’t cause structural damage of the vessel

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2
Q

Peripheral arterial disease

A

Affects arteries alone and damages tissues of vessel walls.
Tissue damage is caused by accumulation of fat

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3
Q

Where is PVD commonly located?

A

lower extremities

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4
Q

What do PVD and PAD have in common?

A

both are progressive that narrow or block blood vessels

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5
Q

What is PAD a marker of?

A

atherosclerosis (gradual thickening of intima and media layers of the arterial wall which causes narrowing)

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6
Q

When does PAD occur?

A

Arterial disease may occur suddenly, following an embolus, or thrombus, or insidiously as in atherosclerosis.

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7
Q

What is the classic symptom of VAD?

A

intermittent claudication (ischemic muscle ache or pain that is caused by exercise and resolves in 10 minutes of rest)

caused by anaerobic cellular metabolism lactic acid

with advanced disease, symptoms happen at rest, in toes and worse at night

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8
Q

When do clinical symptoms occur with PAD?

A

when vessels are 60-70% occluded.

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9
Q

What are physical findings of PAD?

A

smooth, shiny, hairless skin in lower extremities; ↓ or delayed distal pulses

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10
Q

What are symptoms of PAD?

A

Pain or cramping in legs (musclescalf, thigh, or buttocks) during activityand disappears at rest
Numbness and tingling
Slow healing or non-healing sores on toes, feet, or legs
Skin color changes
Poor nail growth
Thinning of skin on legs
Some people do not experience ANY symptoms

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11
Q

What are symptoms of PVD?

A

Dull cramping and pain that comes and goes in the legs
Heaviness or tightness in the leg muscles
Leg or foot that feels cool or cold to the touch compared to the other leg *
Burning sensation *
Leg fatigue, leg or foot feeling cool or cold to the touch
Skin color changes
Loss of leg hair

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12
Q

DX of PVD and PAD

A

for assessing blood flow and outline the vascular system:
Health hx & physical exam
Angiography
Ankle-brachial Index (ABI)
Doppler ultrasound studies

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13
Q

What is the Ankle-Brachial index? (ABI)

A

a peripheral artery disease screening tool
Normal persons:
- SBP in legs slightly higher than in arms (ankle-brachial index > 1.0)
People with PVD:
- ABI decreases (< 1.0)
- Especially before & after exercise

Normal ABI = > 1.0
ABI for pts with claudication = 0.5 - 0.9
ABI for pts with rest pain & critical leg ischemia = < 0.5
Lower the ABI, the greater the arterial impairment

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14
Q

What is the calculation of ankle-brachial index?

A

highest systolic ankle pressure / highest systolic arm pressure

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15
Q

Acute arterial ischemia (AAI)

A
  • 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
  • A thrombus from heart is most frequent cause of acute arterial occlusion (lower extremities)
  • Thrombi that originate in (L) side of heart → majority obstruct an artery of lower extremities (e.g., iliofemoral, popliteal, tibial)
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16
Q

What are the 6 p’s of acute arterial ischemia?

A

Pain
Pallor
Paralysis
Pulselessness
Paresthesia
Pokilothermia (adaption of limb to the environment)

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17
Q

What is the management of PAD?

A
  1. Risk factor modification (Diabetes, smoking, cholesterol, HTN)
  2. Drug therapy
    - Antiplatelet agents, e.g., ASA (ASA + Plavix together NOT recommended – may be used in high risk individuals)
    - Pentoxifylline (Trental) – for intermittent claudication
  3. Exercise: cessation of smoking combined with supervised exercise
  4. Nutritional therapy : to decrease BMI (higher makes it more risky)
  5. Complementary & alternative therapy: vitamin, mineral, herb supplements →but current research data insufficient
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18
Q

What is critical limb ischemia?

A

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) or PVD

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19
Q

What is the therapy for critical limb ischemia?

A

Endovascular procedure
Surgery

reason for surgery = revascularization and decreased CVD event

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20
Q

Endovascular procedure

A

interventional radiological catheter based
1. Percutaneous Transluminal Angioplasty (PTA)
2. Stents
3. Atherectomy
4. Cryoplasty

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21
Q

Percutaneous Transluminal Angioplasty (PTA)

A

to restore blood flow with the use of a balloon-mounted catheter, the tip is advanced to where the stenosis is and inflated (larger opening)

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22
Q

Stents

A

Deployment of expandable metallic devices within the artery immediately after PTA
To treat peripheral artery dissection (tear inner arterial wall)

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23
Q

Atherectomy

A

removal of obstructing plaque with a high-speed cutting disc built into catheter end

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24
Q

Crytoplasty

A

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

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25
Q

Aorto-bifemoral graft

A

Bypass extends from distal aorta to common femoral arteries.
For stenosis of aorta or iliac vessels.
Attached before aorta
redirects blood flow

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26
Q

Femoro-popliteal Bypass

A

For occlusion in superficial femoral artery.
Graft is either a healthy blood vessel or a man-made material.

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27
Q

Femoro-distal Bypass

A

For stenosis in distal vessels. Preferred to use saphenous vein in severe critical ischemia.
Graft extends from femoral to either peroneal or tibial artery.
Patency rate poorer than femoro-popliteal graft

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28
Q

Axillo-bifemoral Graft

A

For aorto-iliac stenosis.

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29
Q

Femoro-femoral Crossover Graft

A

For iliac artery occlusion.

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30
Q

Types of reconstructive surgery

A

Aorto-bifemoral Graft
Femoro-popliteal Bypass
Femoro-distal Bypass
Axillo-bifemoral Graft
Femoro-femoral Crossover Graft

31
Q

Post op care following a peripheral bypass surgery

A

Immediate post op
early recognition of complications
1. ABC
2. VS (q15 min, q30min, & q1hr)
3. check peripheral pulses q1h: dorsalis pedis, posterior tibial using a doppler
- Mark the location
- Loss of pulses, or sudden ↑ of pain should be reported immediately (means graft occlusion)
4. Observe CWMS: report sudden changes
- Use a bed-cradle to aid observation, and protect heels
5. Observe wound for bleeding or hematoma formation
6. Sudden ↑ in output in drainage tube → rupture of graft anastomosis
7. Any indication of graft occlusion or rupture → surgical emergency (feeling of warmth, pain or tenderness, cramping, change in skin colour)

32
Q

Continuing post op care following a peripheral bypass surgery

A

Analgesia for pain (i.e., epidural, or a PCA ) → for 24-48hs or until can take them orally
Preventative Abx – graft infection
Monitor U/O – how many ml/hr should it be? 30 ml /hr
IV fluids via central line (i.e. CVP line)
sliding scale insulin for diabetic patients
O2 as prescribed
Possibility of paralytic ileus (functional problem) in pts with aortic grafts →  stomach should be empty & N/G
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 (Decrease risk of DVT)
- Anti-embolic stockings (if instructed by the surgeon)
- Not recommended for ABI < 0.7 (normal is 1-1.4)
Inspect wounds for signs of inflammation (infection)
Sutures removed 12-14 days post-op
Drainage tubes

33
Q

Aortic Aneurysms

A

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.
- occur in abdo and thoracic area
Dilated aortic wall becomes lined with thrombi.

34
Q

What are the primary causes of aortic aneurysms?

A

Degenerative
Congenital (marfans)
Mechanical
Inflammatory (giant cell arthritis)
Infectious (HIV, syphilis, arthscoutic plaque)

35
Q

How are Aortic Aneurysms classified

A

True or false

36
Q

True aneurysm

A

the wall of the artery forms the aneurysm, and at least one vessel layer is intact
- fusiform (circumferential)
- saccular (pouchlike)

37
Q

False aneurysm

A

AKA pseudoaneurysm
- not an aneurysm but a disruption of all layers of arterial wall → results in bleeding that is contained
- may result from trauma or infection, or at the site of peripheral artery bypass surgery

38
Q

Aortic Aneurysms manifestations

A

Often asymptomatic

39
Q

Thoracic aneurysm manifestations

A

deep diffuse chest pain extending to interscapular area (between shoulder blades)

40
Q

Ascending aorta and aortic arch aneurysm manifestations

A

hoarseness or SOB d/t pressure on laryngeal nerve, angina, TIA

41
Q

Abdominal aortic aneurysm manifestations

A

often asymptomatic, detected on routine physical exam pulsatile mass in periumbilical area slightly left of the midline)
- back pain caused by compression on lumbar nerve & epigastric discomfort

42
Q

Complications of Aortic aneurysms

A

Most serious → rupture of aneurysm
Flank ecchymosis (Grey Turner’s sign)
If ruptured blood leaks into thoracic or abdominal cavity, 90% mortality from hemorrhage

43
Q

What is the goal of treatment for aortic aneurysms?

A

to prevent aneurysm rupture and extension of dissection

44
Q

What is conservative therapy used for in aortic aneurysms?

A

Small, asymptomatic AAAs (4.0 - 5.5cm) -rupture
Size of aneurysm will determine the risk of rupture
Quit smoking, meds for HTN, regular ultrasound surveillance (every 6 months and referral to surgery – greater than 5.5 or 1 cm within a year)

45
Q

What is surgery used for in aortic aneurysms?

A

Rapid expanding aneurysm (> 1 cm diameter increase /year)
When pt becomes symptomatic
High risk of rupture
Involves replacing abdominal aneurysm with a synthetic tube graft

46
Q

Two kinds of surgery for AA

A

Elective and emergency

47
Q

What do we do during preop for elective sx for AA?

A

Hydration
Correction of electrolytes, coagulation (INR), hematocrit abnormalities (RBCs – higher blood loss with higher hematocrit)
Bowel prep (do not want anything in bowel)

48
Q

What is the procedure of an elective sx for AA?

A
  1. Incision of diseased aortic segment
  2. Removal of thrombus or plaque
  3. deployment & suturing of synthetic graft
  4. Most resections done in 30 – 45 min
  5. Requires cross-clamp clamping distal to aneurysm
49
Q

When do we do an emergency sx with AA?

A

ruptured aneurysm –> 100% fatal without emergency sx

50
Q

Emergency sx for AA

A

Only minimal physical preparation is possible
Reassurance and emotional support for pt and family
Lethal complication in repair of ruptured abdominal AA = intra-abdominal hypertension withassociated abdominal compartmental syndrome ( decreases blood flow to organ impaired organ perfusion, multiorgan failure)

51
Q

Sx for abdominal AA

A

Incision of aneurysmal sac
Insertion of synthetic graft
Suturing native aortic wall over synthetic graft

52
Q

Post op care for AAA

A

Typically admits to ICU post-op for 24 - 48hrs
ECG, Endotracheal tube, arterial line, CVP or PA catheter, peripheral IVs, foley catheter, chest tubes ( if thorax opened in surgery), possibly an N/G (for aspiration)
Pain meds: either epidural catheter or PCA
Maintain adequate respiratory function, fluid & electrolyte balance
Assess graft patency
Monitor renal perfusion

Graft patency
CVS
infection
GI
CNS
Peripheral perfusion status
Renal

53
Q

Graft patency care for AAA

A

Adequate BP important: prolonged hypotension results in graft thrombosis
- determine adequate blood flow from urine output, extremities, MAP (BP 2x diastolic + systolic divide by 3) needs to be greater than 60
Severe hypertension may cause undue stress on anastomosis sites (do not want it to burst)
- Treat by Lasix, antihypertensives, diuretics

54
Q

CVS care for AAA

A

Continuous ECG monitoring
- Myocardial ischemia or MI during peri-op due to ↓myocardial O2 supply or ↑ demand
- Dysrhythmia R/T electrolyte imbalance, hypoxemia, hypothermia, or myocardial ischemia
Electrolyte and ABG monitoring
Admin O2
Adequate pain control
Resume cardiac meds

55
Q

Infection care for AAA

A

Vascular graft infection (find def) – artery vein or graft gets infected, can happen soon after surgery or years later, from organisms from the skin
- Admin broad spectrum antibiotic per order
assess IV sites, foley catheter
Assess surgical site for infection

56
Q

GI care for AAA

A

After abdominal aortic surgery, paralytic ileus is possible D/T anaesthesia & manipulation of bowel
- Intestines become swollen & bruised, paused peristalsis
N/G ⇨ low intermittent suction (Risk for aspiration)
Return of bowel function - BS, listening for flatus

57
Q

CNS care for AAA

A

Assess LOC
Glasgow coma scale
With involvement of descending aorta, neurovascular assessment of lower extremities is important

58
Q

Peripheral perfusion status care for AAA

A

Check all peripheral pulses q1h for several hrs (or per protocol) and then per routine
If surgery involves ascending aorta & aortic arch ⇨ emphasis is to assess carotid, radial and temporal pulses
If surgery involves descending aorta
- assess femoral, popliteal, posterior tibial and dorsalis pedis pulses
Mark pulse locations with a felt-tip pen

59
Q

Renal care for AAA

A

Foley cath
Immediate post-op: record U/O q1h maintain 0.5–1 ml/kg/hr
I & O, daily weight until resumes regular diet
Monitor lab work for renal function (BUN, creatinine)
Factors for decreased 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.

60
Q

Aortic Dissection

A

Often misnamed “dissecting aneurysm”, but is NOT a type of aneurysm
Dissection results from creation of a false lumen
Is a tear in aortic intima through which blood enters and creates a false lumen between intima and media of blood vessel

61
Q

How is aortic dissection classified?

A

Anatomical location (ascending, descending)
Duration of onset (acute, chronic)

62
Q

What are the most common type of aortic dissection

A

ascending aorta and acute in onset
chronic - almost always involve descending aorta

63
Q

What are the most common disposing factors of aortic dissection?

A

HTN
Marfan’s syndrome

64
Q

Aortic aneurysm vs aortic dissection

A

Aortic aneurysm occurs when a weak part of aortic wall begins to bulge
Dissection refers to a tear in the aortic lining

65
Q

Type A aortic dissection

A

Originate in ascending aorta, usually within a few cm of aortic valve, and either
1. Extend into descending aorta (TYPE I), or
2. Limited to ascending aorta (TYPE II)

66
Q

Type B aortic dissection

A

or type III
involve only descending aorta; begins farther down aorta (beyond the arch), and extends into abdominal aorta.

67
Q

Patho of aortic dissection

A

Theory: attributes nontraumatic aortic dissection to degeneration of elastic fibers in medial layer
- process accelerated by hypertension
- intimal tear typically occur in the area with greatest rise in BP like immediately above the aortic valve and just distal to the left subclavian artery.

68
Q

Manifestations of acute ascending aortic dissection

A

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.

69
Q

Manifestations for acute descending aortic dissection

A

pain back, abdomen, or legs

70
Q

Manifestations for aortic arch

A

May show neurological deficit e.g., altered LOC, weakened or absence of carotid to temporal pulses, dizziness, syncope

71
Q

What is the management of aortic dissection?

A

Aortic dissection is medical emergency!
Once diagnosis of aortic dissection is suspected, treatment should begin immediately

72
Q

Management of type A dissections

A

high mortality
Requires surgery ⇒ involves replacement with a synthetic graft

73
Q

Management of type B dissections

A

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.

74
Q

Post op care for aortic dissection

A

similar to aortic aneurysm repair

NURS 412 (21 decks)

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