Vascular Surgery - Quiz 3 Flashcards by Kevin Dale

Along with the other common risk factors, Elevated Homocystein & C-Reactive Protein are associated with which disease?

Peripheral Vascular Disease

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What are symptoms of PVD?

Claudication

Skin Ulcers

Gangrene

Impotence

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What are the mortality rates for PVD at 5 & 10 years?

5 years; 30%

10 years: 70%

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How is PVD Treated?

Medications

Transluminal Angioplasty

Endartarectomy

Thrombectomy

Stenting

Arterial Bypass

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What are the different Arterial Bypass procedures used to treat PVD?

Aorto-Fem

Axillo-Fem

Fem-Fem

Fem-Pop

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Peripheral Vascular Occlusive disease may indicate what other areas that may be effected?

Coronary, Cerebral, and Renal Arteries

>50% of motality from PVD is due to PeriOperative Cardiac Events

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What meds can be given d/t high risk of Cardiac Pathology related to PVD?

B-Blockers - decrease O₂ demand and corrects O₂ Supply-Demand mismatch

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What is the primary monitoring objective when for Vascular Surgeries?

Detecting Myocardia Ischemia

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Why is pain control important for Vascular Surgeries?

Pain greatly increases SNS stimulation - pain control improves comfort & cardiac stability

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What are the Contributing Factors of Abdominal Aortic Aneurysms?

Atherosclerosis

HTN

Smoking

Genes

Obesity

Proteolysis of Elastin & Collagen of Vessel Walls

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What are ways used to Diagnose an AAA?

Imaging

Contrast Studies

Digital Subtraction Angiography

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When are Abdominal Aortic Aneurisms at the highest risk for rupturing?

Aneurysms > 5 cm

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What are the AHA Pre-Operative guidelines for managing a patient w/ an AAA?

Glucose Control

Temperature Maintenance

Cardiac Optimization

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What are the Renal Considerations regarding an AAA?

EVAR - stent migration

Contrast Exposure

Clamped Aorta alters Renal Hemodynamics

Hypotension & Perfusion

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What is involved in an EVAR?

Guidewire thru Iliac artery to place a stent graft to restrict flow to the aneurysm. Sheath is deployed and hooks & barbs are placed to prevent stent migration

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What meds are given before an EVAR?

Heparin 50-100 units/kg

ABX - 1st Gen. Cephalosporin

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What are the Advantages of an EVAR?

↑Hemodynamic Stablity

↓Embolic Events

↓Blood Loss

↓Stress, Cortisol, Immune Response

↓Sepsis

↓Renal Dysfunction

↓Post Op Pain

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What are the EVAR complications?

Graft Problems

Iliac Artery Rupture

Low Extremity Ischemia

Ischemic Gut

Endo Leak

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What happens w/ the serious complication of an Endoleak?

Persistent blood flow & pressure b/t graft & aortic aneurysm

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What are Type I & III Endoleaks?

Device Related

Type I: attachment site leak / perigraft channels

Type III: Graft Defect, Tear, Disconnection

Fix w/ second graft or open repair

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What are Type II Endoleaks?

Collateral Retrograde Perfusion involving other Arteries

Spontaneously closes w/in first month

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What is a Type IV Endoleak?

Holes in the Graft

Just observe patient

When is Surgical AAA Repair Contraindicated?

Recent MI

Intractable Angina

Severe Pulm. Dysfunction

Chronic Renal Insufficiency

What makes an AAA repair high risk?

> 85 y.o

Home O2

PaO2 < 50 mmHg

FEV1 < 1 L/s

Creatinine > 3 mg/dL

Severe CHF, CAD, EF < 30%, Ectopy, Angina

Which EKG leads should specifically be monitored for an AAA?

Lead II - Dysrythmias Lead V₅ - Ischemic ST Changes

What is the standard approach to an AAA Procedure?

Transperitoneal to expose _infrarenal_ & iliac vessels as well as intraabdominal organs Ends w/ rapid closure

What are the complications of the Transperitoneal approach for an AAA procedure?

Increased Fluid Loss Prolonged Ileus Post-Op Pain Pulm. Complications Mesenteric Traction Syndrome: Hypotension, Tachycardia, Facial Flushing, ↑CO

What are the advantages of a Retroperitoneal approach for an AAA Procedure?

Exposure to _Justa/SupraRenal_ Aneurysm ↓Fluid Loss ↓Pain ↓Pulm. & GI Complications No Mesenteric Traction Syndrome

What are the sites that Aortic Cross-Clamping can be?

Infrarenal - Most Common Juxtarenal Suprarenal

What are the risks associated with Higher Aortic Cross-Clamping?

Impact on CV System and Vital Organs d/t Hypoperfusion & Ischemia

What are the CV changes w/ Aortic Cross-Clamping?

HTN above Clamp Hypotension Below Clamp Blood Redistribution No Distal Blood Flow ↓CO or No Change ↑PAOP or No Change

What drugs are normally used during Aortic Cross-Clamping?

Vasoactive Drugs Nitroglycerin - ↓Preload & O₂ Demand Dopamine & Dobutamine - ↑CO Nipride - ↓Afterload Isolfurane - ↓SVR

What is the Neuroendrocrine response to Aortic Cross-Clamping?

Inflammation ↑Temp Leukocytosis Tachycardia Tachypnea Fluid Sequestration

Renal Failure may happen from Aortic Cross-Clamping, what can be given to prevent this?

Mannitol before Clamping Dopamine Lasix after Clap Removal Fluids

How can Post-Op Paraplegia happen from an AAA Procedure?

Spinal Cord damage to the Adamkiewicz Artery / Radicular Artery from absence of collateral blood flow d/t higher clamp positions. Maintain the MAP

Ischemia to which vessel can cause Ischemic Colon during an AAA repair?

Inferior Mesenteric Artery that supplies the Left Colon

What happens w/ Declamping Shock Syndrome?

Liberation of Anaerobic Metabolites ↓SVR ↓Venous Return Reactive Hyperemia ↓Preload & Afterload

What is vital to providing circulatory stability _before_ clamp release?

Volume loading Fluids to restore circulating volume to CVP by 3-5mmHg or PAOP by 3-4mmHg

What is the mortality rate for a Rupture AAA?

94% Primary Objective - Hemodynamic stability & Fluid Resuscitation

Besides Abdominal, what are the other types of Aortic Aneurysms?

Thoracic Aortic Aortic Dissection Descending Thoracic Thoracoabdominal

What causes a TIA or Stroke?

Abrupt decrease in Cerebral Blood Flow

How long does a TIA last?

Seconds to Minutes and can happen again after 24 hours No loss of conciousness

Why are Carotid Endarterectomies performed on patients w/ TIAs?

\>50% of strokes happen after a TIA 30% after 2 yrs & 55% after 12 yrs

What are the symptoms of a TIA w/ Vertebral Involvement?

Confusion Dizziness Vision Problems

What are the TIA symptoms when the Carotid is involved?

Unilateral Blindness or weakness

What can be used to Diagnose Cartoid Artery Stenosis?

Duplex Ultrasonography - Definity Arteriography CT MRI

What contributes to poor surgical outcomes for a patient w/ CAD undergoing a CEA?

Myocardial Infarction more than stroke

What does a Positive Dipyridamol-Thallium imaging suggest?

Increased risk of adverse cardiac events

How does brain receive adequate blood flow when the carotid is clamped?

CPP is maintained by collateral blood flow Cerebovascular Autoregulation Shunt may also be placed

What EEG measurements may indicate neuro dysfunction?

Loss of Beta Waves Loss of Amplitude Emergence of Slow Waves

What Carotid stump pressures indicate neuro hypoperfusion?

Stump Pressures \< 40-50 mmHg = neuro hypoperfusion Needs shunt placed

At what MAP does CBF remain constant?

MAP of 60-160 mmHg Chronic HTN shifts curve to the right, needing higher map to ensure adequare Cerebral Perfusion

What are PostOp considerations for CEA's?

HTN Carotid Hemorrhage Neuro Decline Cerebral Hyperperfusion Syndrome

What is the ACT requirement for Carotid Artery Stenting?

\> 250 Seconds Questionable safety and efficacy d/t increased stroke risk Done under Local