Transcript Vascular Surgery

Vascular Surgery
Angie Allen, ACNP
Stacey Becker, RN
Objectives
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Identify our team.
Peripheral Artery Disease
Cerebral Revascularization
Lower Extremity Revascularization
Lower Extremity Amputation
Abdominal Aortic Aneurysms (endovascular)
Thoracic Aortic Aneurysms (endovascular)
Abdominal Aortic Aneurysms (open)
Thoracic Outlet
Who are we?
Attendings
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Dr. Thomas NaslundDivision Chief
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Dr. Raul Guzman
Who are We?
Attendings Continued
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Dr. Jeff Dattilo
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Dr. Colleen Brophy
Who are we?
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Fellows
Dr. Ali Khoobehi
Dr. Syed Rizvi
Interns:
Carry the consult/resident pager:
831-6374
Who are we?
Nurse Practitioner
Angie Allen, ACNP-BC
First Call for Vascular
M-F 0730-1600
886-0163 (cell)
835-8202 (pager)
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Who are we?
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Case Management
Stacey Becker, RN (Dr. Naslund)
Ann Luther, RN
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Social Worker
Ann Lacy, RN
Other Numbers
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Vascular Office: 322-2343
Vascular Clinic: 936-7485
Vascular Lab: 343-9561
Arterial Disease
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Peripheral Artery Disease (PAD): leading case of death
worldwide. Polyvascular disease.
Atherosclerosis: Most likely the cause of PAD. Hardening
of the artery or loss of elasticity.
Arterial Pathophysiology:
1. Occlusive disease: Atherosclerosis is symptomatic by
gradually occluding the artery to the target organ or
extremity. (kidneys, colon, legs, or arms)
2. Symptoms occur with critical arterial stenosis (75 % of
cross sectional of lumen is obliterated)
Arterial Disease
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Aneurysmal Disease: occurs due to loss of
structural integrity of vessel wall. Over time
this will result in dilation and aneurysm
formation.
Cerebral Revascularization
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Symptomatic: Patients who have carotid
stenosis or occlusion that have exhibited a
CVA or TIA
Asymptomatic: Patients who have carotid
stenosis or occlusion that are high risk for CVA
(i.e. hypertension, hyperlipidemia, smoker,
obesity, CAD, etc.)
Symptoms
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Right sided symptoms:
-Left hemiplegia or monoparesis and right eye
visual loss
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Left sided symptoms:
-Right hemiplegia or monoparesis and left
eye visual loss
-aphasia
Symptoms
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Visual symptoms are due to ischemia of the
retina.
Amaurosis fugax
-Transient visual loss
-”Window shade”, “flashing lights”, or
“sparks”
Cerebral Revascularization
Surgical Intervention
Carotid Endarterectomy
Or
Carotid Artery Stenting
Carotid Endarterectomy
Carotid Artery Stenting
Cerebral Revascularization
Post Operative Care
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Neuro Assessment: VERY IMPORTANT. Essential
for recognizing neurological deficits.
Contralateral hemiparesis: technical problem with
endarterectomy with immediate return to OR. Notify
team ASAP. Arterial duplex may be ordered.
Defuse neurological deficit: possible internal capsule
stroke secondary to hypotensive episode.
Delayed neurological deficit: 12-24 hours
postoperatively. Arterial Duplex with possible CTA
of head and neck for evaluation of brain hemorrhage
or CVA and evaluation of carotid.
Post Operative Care
Continued
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Dextran 40: instituted for antiplatelet purposes and
may be continued for 24 hours postoperatively.
NPO until POD 1 for possible exploration.
D5 ½ NS while patient is NPO
POD 1: Initiation of Plavix 75 mg subcutaneous daily
(if no concerns for hematoma)
Incision: Leave dressing dry and intact until POD 1,
may remove. Incision will be closed with disolvable
sutures, leave open to air unless draining.
Cerebral Revascularization
Complications
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Hypertension: 20 % of patients. SBP 100-140
Neck Hematoma: May compromise breathing and
swallowing.
-May require immediate surgical intervention for evacuation
-Order tracheostomy kit Stat to the bedside
Local Nerve Injuries: Most common laryngeal and
hypoglossal nerves presenting as temporary weakness in
speech, swallowing, tongue or lip movement. Less than 0.5%
result in permanent damage.
Hyperperfusion Syndrome: 1-2 % occur 3-7 days post
operatively. Headache, Seizures, and Intracranial
Hemorrhage. Hypertension may accompany. Supportive
management
Cerebral Vascularization
Discharge Instructions
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Incision Care: Leave open to air, unless draining. Wash with
antibacterial soap and water and use white wash cloths.
Immediately call 911 with patient has headache with
associated decreased level of consciousness or seizure
activities.
Follow up in Vascular Clinic 4 weeks postoperatively.
Discharge Medications: Plavix and pain medication
Plavix injection education.
Activity: Do not resume normal work activities until follow
up apt. No driving until that time, do not return to work.
(?????)
Lower Extremity Revascularization
Anatomy
Lower Extremity Vascular Disease
Symptoms
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Claudication: pain at rest, present with ambulation.
Typically seen one level below the disease.
Critical Ischemia: Rest pain may be first symptoms
of severe ischemia. Sharp, localized pain to forefoot
to below the ankle, dependent rubor and pallor with
elevation. 95% loose limb in 1 yr without
revascularization.
Critical Ischemia: Non healing ulcers. (arterial vs
venous)
Critical Ischemia-Gangrene: Skin and subcutaneous
tissue involvement. Dry (noninfected black eschar)
vs Wet (macerated, purulent drainage).
Gangrene-Dry
Symptoms Continued
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Microemboli: Blue Toe Syndrome causes
blue, mottled spots over the toes. May be
painful.
Acute Arterial Ischemia: Sudden onset of
extremity pain, pallor, paresthesia,
pulselessness, and poikilothermia. Caused by
stenotic artery or emboli if no previous
vascular disease.
TREATMENT
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Treatment is based on duration, disability,
progression, general medical condition, non-invasive
diagnostic testing AND pathology
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Non-op management: walking program, lifestyle
modification, with possible medication.
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Diagnostic Testing: Arterial duplex with segmental
pressures/ABI’s (vascular lab), CTA or MRA,
arteriogram, plain films, ECG (if ischemic toes-could
be from a-fib), PT /PTT/INR/Platelet workup.
Operative Managment
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Percutaneous transluminal angioplasty/stenting
Femoropopliteal or Pop-DP, etc. bypass
(saphenous vein, Dakron, ePTFE)
Femoropopliteal percutaneous endovascular
intervention
Aortoiliac or Aortobifemoral bypass or
angioplasty with or without stenting
Thromboembolectomy
Amputation
Post-Operative Care
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ICU stabilization after aortic operations
(stability of vitals/hemodynamics, respiratory,
fluid, electrolyte, cardiac, laboratory -pcv,
blood glucose, lytes, coags- management).
Fluids: D51/2 NS 20 KCL at 75 mL/hr
Rewarm and vasodilate: bolus may be
warranted
Post op day 3-4: mobilization of fluids-may
see lasix given.
Post-Operative Care Continued
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Pain Control: essential for mobilization. PCA or
percocet or lortab
Ambulation: PT/OT consult, POD 1
Rooke Perioperative Boots
Antibiotics: continued for 24 hours
Wound Care: remove dressing POD 1, may leave
open to air unless draining. Wash with antibacterial
soap and water and use white wash cloths.
Amputation Wounds: Takedown is on POD 2, will
require knee immobilizer.
High Risk for Pressure Ulcers
Complications
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Hemorrhage from graft: Exploration required.
Thrombis (graft occlusion) PULSES< PULSES<PULSES
Infection
Stage 1: Involving skin and dermis-wound care,
antibiotics.
Stage 2: Extending to subcutaneous and fatty tissue but
not graft-Exploration and washout in the OR, continued
wound care and antibiotics.
Stage 3: Graft involvement-Exploration and washout in
the OR with graft removal with establishment of new route of
perfusion. Continued wound care and 6 weeks of IV
antibiotics.
Complications Continued
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Compartment Syndrome: Caused by
prolonged ischemia (> 6 hrs) then
revascularization resulting in edema in the calf
muscles. Leg pain with sensory deficits to the
dorsum of the foot and weakness of toe
dorsiflexion. Measure Compartment Pressure.
Treatment: fasciotomy.