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CV Test 3 > Vascular Surgery & Hypertension > Flashcards

Vascular Surgery & Hypertension Flashcards

1
Q

What “branches” off of the ascending aorta?

A

Coronary arteries

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2
Q

What are the branches off of the aortic arch?

A

Innominate artery/brachiocephalic
Left common carotid
Left subclavian

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3
Q

What branches come off of the brachiocephalic?

A

Right subclavian

Right common carotid

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4
Q

Why should an arterial line always be placed in the right arm during a mediastinoscopy?

A

If the aorta is compressed during mediastinoscopy, the first vessel affected would be the innominate so monitoring a-line in the right arm would monitor perfusion

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5
Q

How is monitoring with an A-line in the right arm also a monitor of brain perfusion during a mediastinoscopy?

A

This also monitors perfusion to the brain because the right carotid comes off the innominate

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6
Q

What determines where the A-line is placed for an ascending aortic aneurysm?

A

Location of the surgeon’s cross-clamp

-surgeon may put in a femoral line

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7
Q

What can an asceding aortic aneurysm also affect?

A

The aortic valve

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8
Q

What diseases are aortic dissections associated with?

A

Marfan’s

Hypertension

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9
Q

Where are traumatic aortic dissections more common?

A

In the ascending aorta

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10
Q

Where are aortic aneurysms more common?

A

In the abdominal aorta

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11
Q

Where is aortic occlusive disease more common?

A

At aortic bifurcation

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12
Q

What medication is required with aortic cross clamping?

A

Heparinization

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13
Q

What besides blood can anesthesia give to prevent clot breakdown?

A

Antifibrolytics

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14
Q

What does an aortic cross clamp do to afterload?

A

Increases afterload

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15
Q

The increased afterload due to aortic cross clamping can have what negative effects on the heart?

A

Increases LV pressure required may > LV failure

Increases O2 demand > ischemia

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16
Q

What device is common to use during aortic cross clamping in order to monitor afterload and the heart’s response to this increase?

A

PA catheter

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17
Q

What vasodilator is used during aortic cross clamping in order to help decrease resistance?

A

NTG

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18
Q

Why is an arterial dilator (Nipride) not used in aortic cross clamping in order to decrease afterload?

A

May decrease spinal cord perfusion pressure by both decreasing distal aortic pressure and increasing CSF pressure

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19
Q

What does anesthesia want to give before cross clamp is removed? Why?

A

Volume

Because when the clamp is removed there is a sudden drop in afterload

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20
Q

What happens when the cross clamp is removed?

A

Sudden drop in afterload > hypotension

-turn NTG off

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21
Q

What is a risk with all surgeries that invovles aortic cross clamping?

A

Acute kidney injury

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22
Q

What increases the risk of kideny injury with aortic cross clamping?

A

longer cross clamping times
emergency surgery
pre-existing renal disease

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23
Q

What kidney injury prevention attempts have been tried, none of which are successful?

A

Mannitol
Furosemide
Fendolopam
Dopamine

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24
Q

What makes ascending aorta repairs more risky?

A

Disscetions or tears can extend back into valve

  • surgery is similar to AVR but:
  • longer surgery time
  • more blood loss
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25
Q

What is circulatory arrest? When is it utilized?

A

Surgical technique that involves deep hypothermia and stopping circulation
Ascending aortic repairs

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26
Q

Why is circulatory arrest utilized in ascending aorta dissections or tears?

A

Perfusion is difficult even with CPB, profound hypothermia decreases metabolism and reduce risk of ischemia

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27
Q

What is unique about descending aorta incision and ansethesia?

A

Thoracolumar incision and one lung anesthesia

-sternotomy can be done if needed

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28
Q

Why is one lung ansethesia performed during descending aorta repair?

A

Makes more room for surgeon to work

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29
Q

Where are aoritc clamps placed during descending aortic repair?

A

Above and below the site

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30
Q

What does cross clamping above and below the descending aortic repair do to circulation?

A

Circulation is isolated into 2 separate systems

  • femoral cannulation for CBP of lower body
  • upper body perfusion via heart and lungs
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31
Q

What risk does double cross clamping the descending aorta carry?

A

Paraplegia due to inadequate spinal cord perfusion

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32
Q

Why is paraplegia a risk with descending aorta repair surgery?

A

The main radicular artery that perfuses the spinal cord is the Artery of Adamkiewicz, it’s location varies among the population, so it is unknown if it is affected by clamp until postop

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33
Q

What percetage of the population have the artery of adamkiewicz coming off T5-T8?

A

15%

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34
Q

What percetage of the population have the artery of adamkiewicz coming off T9-T12?

A

60%

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35
Q

What percetage of the population have the artery of adamkiewicz coming off L1-L2?

A

25%

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36
Q

How can anesthesia help protect the spinal cord during descending aorta repair?

A 
Steroids
Hypothermia
Mannitol
Lumbar CSF drainage
Avoid excessive vasodilator administration with cross clamp afterload elevation
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37
Q

How does removing some lumbar CSF help protect the spinal cord?

A

Decreases CSF pressure > less tissue pressure for vascular to push against and get spinal cord perfused

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38
Q

Where is an infrarenal cross clamp of the aorta? Does this risk renal failure?

A

Below the kidneys

Yes

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39
Q

Where is a suprarenal cross clamp of the aorta? Does this risk renal failure?

A

Above the kidneys

Yes

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40
Q

What less invasive technique for repairing dissection or aneurysm removes the need for aortic cross clamping?

A

Endovascular stents

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41
Q

Where can endovascular stenting be used in aortic repairs?

A

Anywhere

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42
Q

What could be suspected in a person with peripheral vascular disease from plaque?

A

They are prone to plaque, so it is reasonable to suspect there may be plaque in the coronaries and/or carotids

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43
Q

Lower extremity peripheral vacular bypass graft procedures done with regional anesthesia have what benefits for the graft?

A

Increase graft flow and decrease graft thrombosis

44
Q

Peripheral vascular surgeries for bypass

A

Femoral popliteal bypass
Femoral to femoral bypass
Aorta bi-femoral bypass

45
Q

Hypertension does what to vascular tone?

A

Causes chronic vasoconstriction

46
Q

What does this chronic vasoconstriction mean for volume status?

A

Chronic volume depletion due to less vascular space for fluid

47
Q

What used to treat hypertension also affects chronic volume depletion?

A

Diuretics

48
Q

What happens to the kidney with chronic volume depletion from volume depletion and/or chronic constriction of the renal vasculature?

A

Kidneys are under perfused

49
Q

What response do the kidney have due to under perfusion?

A

Triggers renin, angiotensin, aldosterone

50
Q

What overall effect does the trigger of RAAS have?

A

Retain fluid in an attempt to increase renal blood flow

51
Q

What diseases are associated with hypertension?

A

CAD
PVD
Carotid disease
Renal dysfunction

52
Q

How does hypertension affect autoregulation?

A

It shifts the autoregulation curve to the right

53
Q

What does a right shift in the autoregulation curve mean?

A

The range for autoregulation function is higher

-patients needs a higher BP to maintain autoregulation

54
Q

What are the advantages of continuing BP medications preop?

A

No rebound hypertension
-more stable BP, less labile
Less angina/ischemia
Lower morbidity and complications

55
Q

What is the DBP “red flag” value for HTN and that May case should be postponed?

A

110 mmHg

-consider postponement if elective procedure

56
Q

Why is continued preop use of ACE inhibitors and ARBs controversial?

A 
Possible refractory hypotension under anesthesia when continued
-only class that is sometimes held
57
Q

What benefits does continuing beta blockers preop have?

A

Smoother induction

-consider additional dose

58
Q

Should BB be given preop to those not on them?

A

Risks out weigh benefits

  • Fewer MIs and arrhythmias
  • More strokes and deaths
59
Q

What do all calcium channel blockers cause?

A

Myocardial depression

-so does VA and BB

60
Q

What can be given for a coronary vasospasm?

A

Calcium channel blocker

61
Q

What happens in a HTN patient during induction (BP wise)?

A

Labile BP

  • induction agent vasodilates them > hypotension
  • stimulation > HTN
62
Q

What makes lability of BP worse in HTN patients?

A

If they are volume depleted

63
Q

With poor preop control of BP what are they at higher risk for?

A

Ischemia

64
Q

What also increases the risk of ischemia?

A

Hypotension

-HTN is better than hypotension

65
Q

What helps reduce the labile BP swings?

A 
Fluid
Induction-adequate depth
-fentanyl
-lidocaine
Adjunct BB dose or sodium nitroprusside
66
Q

What is the danger of hypotension in a HTN patient?

A

Poor organ perfusion

-autoregulated orgran now require higher BP to maintain perfusion

67
Q

Why is hypertension a significant cause of congestive heart failure and cardiomyopathy?

Nagelhout

A

Because it causes increased afterload from chronic vasoconstriction

68
Q

Hypertension increases the likelihood of the development of what?

A

Atherosclerosis

-and thus chronic and untreated HTN increases risk of MI, stroke and chronic kidney injury

69
Q

What is essential hypertension?

A

AKA primary and idiopathic

  • has no identifiable cause
  • diagnosed on the basis of exclusion
70
Q

What is remedial hypertension?

A

AKA secondary hypertension

-has an identifiable and potentially curable cause

71
Q

What is concentric hypertrophy?

A

Hypertrophy that occurs in response to chronic increases in intracardiac pressures
- Chronic HTN and increased afterload > hypertrophy of LV

72
Q

Does LV hypertrophy affect the O2 supply and demand balance?

A

Yes, it increases demand

73
Q

All patients with chronic HTN should be suspected of having?

A

Some degree of coronary artery disease

74
Q

What medications have been found to help with refractory hypotension from ACE inhibitors and ARBs?

A

Vasopressin and methylene blue

75
Q

Patient with DBP great than what have a significantly increased risk of perioperative cardiac morbidity?

A

110 mmHg
-may be modified in patients with HTN in whom DBPs greater than 110 occur frequently despite aggressive antihypertensive therapy

76
Q

Why may Etomidate offer some advantages in patients with cardiac pathology as compared to Propofol?

A

Etomidate preserves SV and CO

77
Q

Intraluminal stent grafts have been approved for aneurysms of what size?

Co-existing

A

Above 5.5 cm

-as well as complicated type B dissections

78
Q

Chronic impairment of blood flow to the extremities is most often due to what?

A

Atherosclerosis

79
Q

Acute arterial occlusion is mostly likely from?

A

Embolism

80
Q

What is an ankle-brachial index? (ABI)

A

The calculated ratio of SBP at the ankle to the SBP in the brachial artery

81
Q

What does the ABI define?

A

An ABI of less than 0.9 is the most widely accepted definition of peripheral arterial insufficiency

82
Q

Why does intermittent claudication occur with peripheral arterial disease?

A

When the metabolic requirement of exercising skeletal muscles exceeds oxygen delivery

83
Q

Why does rest pain occur with peripheral artery disease?

A

The arterial blood supply does not even meet the minimal nutritional requirements of the affected extremity

84
Q

What are the risk factors associated with development of peripheral atherosclerosis?

A 
Older age
Family Hx
Smoking 
DM
HTN
Obesity
Dyslipidemia
85
Q

What are the most reliable physical findings associated with PAD?

A

Decreased or absent arterial pulses

-buits may indicate the anatomical site of arterial stenosis

86
Q

Signs of chronic leg ischemia?

A 
SQ atrophy
Hair loss
Coolness
Pallor
Cyanosis
Dependent redness
87
Q

Reduced lower extremity pulses may be the presenting sign of what (less commonly)?

A

Undiagnosed aortic coarctation

88
Q

What is an aortic dissection?

M and M

A

An intimal tear that allows blood to track into the aortic wall (the media)

89
Q

Who diseases put patient at risk of aortic dissection?

A

Marian syndrome and Ehlers-Danlos syndrome > cystic medial necrosis > aortic dissection

90
Q

What aortic dissections are most common?

A

Proximal type involving the ascending aorta

91
Q

Where do aortic aneurysms more commonly occur?

A

In the abdominal vs thoracic aorta

92
Q

What is the most common cause of aortic aneurysms?

A

Atherosclerosis

93
Q

What is a pseudoaneurysm?

A

When the intima and media are ruptured and only adventitia or blood clot forms the outer layer

94
Q

When is elective treatment of aortic aneurysms generally performed?

A

With aneurysms 5 cm or greater

95
Q

Where does atherosclerotic obliteration of the aorta (Occlusive disease of the aorta) most commonly occur?

A

Near the aortic bifurcation

-Leriche syndrome

96
Q

What is coarctation of the aorta?

A

A congenital narrowing of the aorta

97
Q

What is preductal (infantile) type coarctation of the aorta?

A

Lesion is proximal to the opening of the ductus arteriosis

-recognized in infancy because lower extremities are cyanotic

98
Q

What is postductal coarctation of the aorta?

A

Lesion is after the ductus arteriosus

  • may not be recognized until adulthood
  • symptoms and hemodynamic significance depend on severity of narrowing and the extent of collateral circulation
  • HTN in the upper body is usually present
  • “rib notching” on CXR may be present d/t dilated collateral intercostal arteries
99
Q

What aortic procedures are usually performed with median sternotomy, CPB and deep hypothermic circulatory arrest?

A

Surgery on the ascending aorta

Surgery on the aortic arch

100
Q

This aortic surgery may be complicated by long aortic cross clamp times and large intraoperative blood loss?

A

Ascending aorta

101
Q

What aortic surgery can be performed with a left thoracotomy with or without CPB?

A

Surgery involving the descending thoracic aorta

102
Q

Surgery on the descending thoracic aorta involves cross clamping the aorta above and below the lesion, what does this do to BP?

A

Acute hypertension develops above the clamp and hypotension below (when there is no shunt or partial bypass)

103
Q

During surgery involving the descending thoracic aorta, when is the period of greatest hemodynamic instability?

A

Following the release of the aortic cross clamp
-abrupt decrease in afterload together with bleeding and release of vasodilation acid metabolites from the ischemic lower body can precipitate severe hypotension

104
Q

Spinal cord perfusion pressure =

A

MAP - CSF pressure

105
Q

In general, the more distally the clamp is applied to the aorta what affect does this have on LV afterload

A

The more distally the clamp is placed the less effect on LV afterload

CV Test 3 (3 decks)

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