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46 Cards in this Set

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Ascending Aorta
Aortic Valve to inominate artery
Aortic Arch
Inominate artery to Left subclavian
Thoracic aorta
Distal to Left Subclavian to diaphragm
Abdominal Aorta
Diaphragm to iliac arteries
Aortic vessel anatomy
Intima-innerrmost layer;
Media-muscle layer, aneurysm formation;
Adventitia-outermost layer
Etiology of aorto-iliac occlusive disease:
Atherosclerosis, risk factors include: DM, HTN, male gender, tobacco, and genetics
*Lesions most likely form at orgins of vessels and bifurcations
Stage Progression of aorto-iliac occlusive disease:
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)
Indication for Surgery for aorto-iliac occlusive disease:
Symptoms of ischemia: non-healing lesion on lower extremity, claudication, erectile dysfunction
Aortic Surgery Preop Evaluation
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
Major Clinical Predictors of Increased Perioperative Cardiovascular Risk:
Major: Unstable coronary syndromes, decompensated CHF, significant arrhythmias, severe valve disease;
Intermediate Clinical Predictors of Increased Perioperative Cardiovascular Risk:
Intermediate: mild angina pectoris, prior MI, compensated or prior CHF, DM, renal insufficiency
Minor Clinical Predictors of Increased Perioperative Cardiovascular Risk:
Minor: advanced age, abnormal ECG, rhythm other than sinus, low functional capacity, hx of CVA, uncontrolled systemic HTN
Noninvasive testing in preoperative patients indicated if 2 or more of following present:
-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)
Specific noninvasive testing:
-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
Test of choice for assessment of risk for CAD and Functional Capacity
Exercise ECG test (treadmill-provides estimate of functional capacity & detects myocardial ischemia thru ECG changes and hemodynamic response
Class I Recommendations for Coronary Angiography in Perioperative Evaluation
Class I: Patients with suspected or known
CAD
Class IIa Recommendations for Coronary Angiography in Perioperative Evaluation
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.
Class IIb Recommendations for Coronary Angiography in Perioperative Evaluation
1. Perioperative MI.
2. Medically stabilized severe angina and
planned low-risk or minor surgical procedure
Class III Recommendations for Coronary Angiography in Perioperative Evaluation
Preoperative CABG
–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.
Preoperative Percutaneous coronary intervention (PCI)
–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
Preoperative Medications
Anesthetic Goals for intraoperative management:
Preserve end-organ perfusion.
Stress Reduction intraoperative management:
Surgical approaches aortic surgery:
Advantages of Retroperitoneal approach to aortic surgery:
Reduction in:
Anesthetic techniques for intraoperative management aorta surgery:
Induction Aorta surgery:
Management of blood & fluids for aorta surgery:
Renal issues aorta surgery:
Miscellaneous considerations aorta surgery:
Complications of Aorta sugery: Hemorrhage
Hemorrhage:
Complications of Aorta sugery: Limb ischemia
Limb ischemia:
Complications of Aorta sugery: Iatrogenic injury
Iatrogenic injury:
Complications of aorta surgery: Intestinal ischemia
Intestinal ischemia:
Complications of aorta surgery: Myocardial ischemia/injury
Myocardial ischemia/injury:
Factors that increase Myocardial O2 Demand:
Increased:
-HR
-Contractility
-Diastolic Volume
-Blood Pressure
Factors that decrease Myocardial O2 Supply:
Decreased Coronary Blood Flow:
-Increased HR
-Increased Diastolic Volume
-Coronary Vasoconstriction
-Coronary Thrombosis

Decreased O2 content:
-Decreased HCT
-Decreased O2 saturation
Complications of aorta surgery: Spinal cord ischemia
Spinal cord ischemia:
Complications of aorta surgery: Renal Failure
Renal Failure:
Emergence from aorta surgery:
Postoperative Management aorta surgery:
Risk of myocardial infarction
Postoperative Management aorta surgery:
Hypothermic Patients
Postoperative Management aorta surgery: Oliguria
Postoperative Management aorta surgery:
Analgesia
Postoperative Management aorta surgery:
Late complications