Aortic Surgery

Front 1

Ascending Aorta

Back 1

Aortic Valve to inominate artery

Front 2

Aortic Arch

Back 2

Inominate artery to Left subclavian

Front 3

Thoracic aorta

Back 3

Distal to Left Subclavian to diaphragm

Front 4

Abdominal Aorta

Back 4

Diaphragm to iliac arteries

Front 5

Aortic vessel anatomy

Back 5

Intima-innerrmost layer;
Media-muscle layer, aneurysm formation;
Adventitia-outermost layer

Front 6

Etiology of aorto-iliac occlusive disease:

Back 6

Atherosclerosis, risk factors include: DM, HTN, male gender, tobacco, and genetics
*Lesions most likely form at orgins of vessels and bifurcations

Front 7

Stage Progression of aorto-iliac occlusive disease:

Back 7

1. Fatty streaks on endothelium
2. Fibrous plaque covered by smooth muscle
3. Complex lesion of atherosclerosis (plaque expands with lipid core, accumulates calcium, disrupts endothelium and forms thrombus)

Front 8

Indication for Surgery for aorto-iliac occlusive disease:

Back 8

Symptoms of ischemia: non-healing lesion on lower extremity, claudication, erectile dysfunction

Front 9

Aortic Surgery Preop Evaluation

Back 9

Surgery of aorta patients have 50% incidence of CAD;
Evaluate cardio-pulm status;
Evaluate end-organ function (kidneys, liver);
Cardiology consult with specific requests prn

Front 10

Major Clinical Predictors of Increased Perioperative Cardiovascular Risk:

Back 10

Major: Unstable coronary syndromes, decompensated CHF, significant arrhythmias, severe valve disease;

Front 11

Intermediate Clinical Predictors of Increased Perioperative Cardiovascular Risk:

Back 11

Intermediate: mild angina pectoris, prior MI, compensated or prior CHF, DM, renal insufficiency

Front 12

Minor Clinical Predictors of Increased Perioperative Cardiovascular Risk:

Back 12

Minor: advanced age, abnormal ECG, rhythm other than sinus, low functional capacity, hx of CVA, uncontrolled systemic HTN

Front 13

Noninvasive testing in preoperative patients indicated if 2 or more of following present:

Back 13

-Intermediate clinical predictors
-Poor Functional Capacity (<4METs)
-High Surgical risk procedure (emergency major surgery, aortic or peripheral vascular repair, prolonged surgical procedures with large fluid shifts, blood loss)

Front 14

Specific noninvasive testing:

Back 14

-Excercise stress test-preferred noninvasive test;
-Nonexercise stress test: infusion of dobutamine stress echocardiography (have other limiting dx) or Myocardial perfusion imaging-thallim scan to find fixed lesion-give drug to dilate CA and if dx won't dilate;
-Ambulatory electrocardiographic monitoring

Front 15

Test of choice for assessment of risk for CAD and Functional Capacity

Back 15

Exercise ECG test (treadmill-provides estimate of functional capacity & detects myocardial ischemia thru ECG changes and hemodynamic response

Front 16

Class I Recommendations for Coronary Angiography in Perioperative Evaluation

Back 16

Class I: Patients with suspected or known
CAD

Front 17

Class IIa Recommendations for Coronary Angiography in Perioperative Evaluation

Back 17

1. Multiple markers of intermediate clinical risk and planned
vascular surgery (noninvasive testing should be considered
first).
2. Moderate to large region of ischemia on noninvasive
testing but without high-risk features and without lower
LVEF.
3. Nondiagnostic noninvasive test results in patients of
intermediate clinical risk undergoing high-risk noncardiac
surgery.
4. Urgent noncardiac surgery while convalescing from acute
MI.

Front 18

Class IIb Recommendations for Coronary Angiography in Perioperative Evaluation

Back 18

1. Perioperative MI.
2. Medically stabilized severe angina and
planned low-risk or minor surgical procedure

Front 19

Class III Recommendations for Coronary Angiography in Perioperative Evaluation

Front 20

Preoperative CABG

Back 20

–No randomized clinical trials documenting
decreased incidence of perioperative cardiac
events
– Patients with prognostic high risk coronary
anatomy in whom long-term outcome would
likely be improved. (ACC/AHA CABG
Guidelines)
–Noncardiac elective surgical procedure of
high or intermediate risk.

Front 21

Preoperative Percutaneous coronary intervention (PCI)

Back 21

–No randomized clinical trials documenting
decreased incidence of perioperative cardiac
events
–No prospective studies to determine optimal
period of delay after PCI before noncardiac
surgery

Front 22

Preoperative Medications

Front 23

Anesthetic Goals for intraoperative management:

Back 23

Preserve end-organ perfusion.

Front 24

Stress Reduction intraoperative management:

Front 25

Surgical approaches aortic surgery:

Front 26

Advantages of Retroperitoneal approach to aortic surgery:

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Reduction in:

Front 27

Anesthetic techniques for intraoperative management aorta surgery:

Front 28

Induction Aorta surgery:

Front 29

Management of blood & fluids for aorta surgery:

Front 30

Renal issues aorta surgery:

Front 31

Miscellaneous considerations aorta surgery:

Front 32

Complications of Aorta sugery: Hemorrhage

Back 32

Hemorrhage:

Front 33

Complications of Aorta sugery: Limb ischemia

Back 33

Limb ischemia:

Front 34

Complications of Aorta sugery: Iatrogenic injury

Back 34

Iatrogenic injury:

Front 35

Complications of aorta surgery: Intestinal ischemia

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Intestinal ischemia:

Front 36

Complications of aorta surgery: Myocardial ischemia/injury

Back 36

Myocardial ischemia/injury:

Front 37

Factors that increase Myocardial O2 Demand:

Back 37

Increased:
-HR
-Contractility
-Diastolic Volume
-Blood Pressure

Front 38

Factors that decrease Myocardial O2 Supply:

Back 38

Decreased Coronary Blood Flow:
-Increased HR
-Increased Diastolic Volume
-Coronary Vasoconstriction
-Coronary Thrombosis

Decreased O2 content:
-Decreased HCT
-Decreased O2 saturation

Front 39

Complications of aorta surgery: Spinal cord ischemia

Back 39

Spinal cord ischemia:

Front 40

Complications of aorta surgery: Renal Failure

Back 40

Renal Failure:

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Emergence from aorta surgery:

Front 42

Postoperative Management aorta surgery:
Risk of myocardial infarction

Front 43

Postoperative Management aorta surgery:
Hypothermic Patients

Front 44

Postoperative Management aorta surgery: Oliguria

Front 45

Postoperative Management aorta surgery:
Analgesia

Front 46

Postoperative Management aorta surgery:
Late complications