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what is the most common cause of occlusive disease?

Assume presence of underlying ___ (SINGLE MOST IMPORTANT risk factor in long term survivability)

Assume presence of underlying CAD (SINGLE MOST IMPORTANT risk factor in long term survivability)
what is Goldman cardiac risk index?
  • Advanced age
  • Cardiac history
  • Aberrations on physical exam
  • ECG abnormalities
  • Previous surgical procedures
what is cooperman and associates risk factors?
  • Angina
  • CHF
  • Dysrhythmias
  • MI
  • CVAs
  • Abnormal ECG
what tests can be done as part of preop eval?
  • coronary angio
  • thellium stress test
  • echo
  • ECG
  • Exercise tolerance
what is the most reliable preop test pre op?
caronary angio
how to optimize cardiac function using medical therapy?
  • Pharmacology continue all cardiac meds up to surgery
  • Prevent withdrawal from B-blockers
  • Avoid immediate pre-op ACE inhibitors – hypotension
how to optimize cardiac function using cardiac revascularization?
Revascularization prior to surgery (CABG or angioplasty)
how to optimize pulm function?

  • Antibiotics for chronic bronchitis
  • Cessation of smoking
  • Incentive spirometry
  • Appropriate use of bronchodilators
how to optimize renal fxn?

  • Remember pts more sensitive to toxicity related to arteriographic contrast agents
  • Must be watched closely to ensure renal function is not diminished during diagnostic evaluation
  • Post-op renal failure in this population carries a 50% mortality rate
how to optimize cerebrovascular circulation?

  • Decreased ability to autoregulate cerebral blood flow may be present
  • Require tighter control of blood pressure intraoperatively

What is the risk associated with major vascular surgery in patients with co-existing diseases?
▪Mortality of ~ 5% ▪If patient has poorly controlled CHF (S3 gallop or distended neck veins) then mortality increases to ~ 20%
what are the cardiovascular benefits of epidural technique for vascular surgery?
  • Decrease myocardial O2 demand
  • Decreases myocardial infarct size
  • Causes fewer sympathetic BP swings
  • Less blood loss
  • Use less general anesthesia depressant meds
  • Redistributes blood to lower extremities
what are the pulm benefits of epidural technique for vascular surgery?
  • Decreases FVC, FEV1
  • Requires less shunting O2 consumption
  • Less pulmonary infections
  • Fewer thromboembolisms
  • Earlier extubation
what are the renal benefits of epidural technique for vascular surgery/
  • Increases blood flow to renal cortex
  • Causes less renovascular constriction

what are the endocrine benefits of epidural for vasc surgery?
  • Inhibits surgical stress response
  • Inhibits adrenaline and cortisol release
  • Inhibits hyperglycemia
  • Blocks sympathetic tone
what is GA technique for unstable pts?
Ketamine, etomidate, or small amounts of opioids and benzodiazepines
what is GA technique for stable pts?
  • Gradual gentle controlled induction to avoid tachycardia and HTN
  • LTA kit to blunt intubation
what is GA technique for pts w poor ventricular fxn?
  • High-dose opioid (depress cardiac contractility less)
  • Combo with regional
what is the MOST common site of major atherosclerotic involvement below the inguinal ligament?

The superficial femoral artery is the MOST common site of major atherosclerotic involvement below the inguinal ligament!
what does external iliac "splits" into?

The external iliac continues as the femoral artery and the deep femoral artery
what does femoral artery become behind the knee?

Femoral artery becomes popliteal artery behind the knee
what does femoral artery divides into passed the knee?

divides into anterior and posterior tibial arteries
list the types of occlusion
acute and chronic arterial occlusion
what type of occlusion is primarily result of emboli or thrombosis?
acute arterial
where do most acute arterial occlusion originate?
Most emboli originate in the heart (A-fib, prosthetic heart valves, and MI are causes)
what are the most common sites of arterial occlusion?
Common sites include fem artery bifurcation, iliac artery bifurcation, and popliteal artery
what is claudication?
  • Pain or fatigue in the muscles of lower extremity caused by exertion and relieved with rest
  • Pain usually in muscle group distal to arterial insufficiency
what are the indications for elective lower ext vasc surgery?
  • Claudication
  • Ischemic rest pain or ulceration
  • Gangrene
what is inflow reconstruction?
  • Bypass of obstruction in the aortoiliac segment
  • Most common: aortofemoral bypass
what is outflow reconstruction?
  • Performed distal to the inguinal ligament for bypass of femoral popliteal or distal obstructions
  • Most common: common femoral artery to popliteal or tibial artery

Patient needs to be well hydrated and normotensive to prevent ____ _____

Patient needs to be well hydrated and normotensive to prevent peripheral vasoconstriction
what are the advantages of regional?
  • Avoids hyperdynamic response to intubation/incision/extubation
  • Reduces incidence of resp and infectious complications
  • Reduces post-op hypercoagulability and graft thrombosis
  • Post-op analgesia
what are disadvantages of regional?
  • Poor patient tolerance for long procedure
  • Any absolute or relative contraindications (anticoagulants often given if emergent may rule out use of regional)
  • Sympathectomy requires some volume loading
what are the advantages of GA?
  • Controlled airway
  • Hemodynamics easily controlled
  • Reliable
  • Patient comfort with long cases
what are the disadvantages of GA?
  • Hyperdynamic state post-op
  • Hypercoagulable state post-op (fibrinolysis is decreased after GA)
  • Fluctuations in catecholamine levels
  • Greater changes in respiratory dynamics
  • Post-op pain control options limited
avoid Hgb less than what?
what is the formula for SC perfusion pressure?
SC perfusion pressure = ABP – CSF Pressure
what happens to CSF and ABP below the clamp?
increase of CSF and decrease of ABP
special considerations for anesthetic managemt of ascending aorta
  • Long aortic cross clamp times 
  • Large blood loss
  • Right radial A-line
anesthetic management of aortic arch

Goal- **Cerebral Protection
  • Hypothermia
  • Thiopental infusion
  • Maintain flat EEG
  • Corticosteroids
  • Free radical scavengers
what is most significant factor in development of post-op stroke?
pre-op neurological dysfunction
what can deter optimal surgical positioning?

Cervical arthritis and spondylosis

Check for history of ____with extreme head positioning

Check for history of TIA with extreme head positioning
how should you intubate pts for CEA?

Intubate in the neutral position or “awake” (if general anesthetic planned)
what are the anesthetic management goal for CEA?
  • To protect heart and brain from ischemic injury
  • Control heart rate and BP
  • Ablate surgical pain and stress responses
  • AND…have ”awake” patient at end of surgery to assess neurological status
what is a dominant factor in maintaining CPP during CEA?

MAP becomes dominant factor in maintaining CPP
when is CPP unchanged, what MAP range?

CBF unchanged if MAP between 60-160 mmHg (autoregulation)
what are the advantages of regional anesthesia for CEA?
  • Major advantage is an awake pt for continual neurological monitoring
  • Requires cooperative patient
  • May be reduction in “non-neurological” complications such as MI or pulmonary insults (no intubation)
  • Affords greater hemodynamic stability
  • Shorter operating time and hospital stay, fewer shunts needed, lower incidence of perioperative hypertension
what are the disadvantages of regional anesthesia for CEA?
  • Uncomfortable positioning for patient
  • Cross-clamping may cause LOC, apnea, seizures, and patients inability to cooperate
  • Pain &/or anxiety may increase HR & BP (MI)
  • Complications of block—total spinal or seizures
  • Can not provide “thiopental brain protection”
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