Vascular Surgery - 1 includes:
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Vascular Surgery - 1 includes: Vascular Surgery - 1 includes: Presentation Transcript

  • Vascular Surgery Angie Allen, ACNP Stacey Becker, RN
  • Objectives
    • 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
    • Dr. Thomas Naslund-Division Chief
    • Dr. Raul Guzman
  • Who are We? Attendings Continued
    • Dr. Jeff Dattilo
    • Dr. Colleen Brophy
  • Who are we?
    • 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)
  • Who are we?
    • Case Management
    • Stacey Becker, RN (Dr. Naslund)
    • Ann Luther, RN
    • Social Worker
    • Ann Lacy, RN
  • Other Numbers
    • Vascular Office: 322-2343
    • Vascular Clinic: 936-7485
    • Vascular Lab: 343-9561
  • Arterial Disease
      • 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
    • Aneurysmal Disease: occurs due to loss of structural integrity of vessel wall. Over time this will result in dilation and aneurysm formation.
  • Cerebral Revascularization
    • 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
    • Right sided symptoms:
    • -Left hemiplegia or monoparesis and right eye visual loss
    • Left sided symptoms:
    • -Right hemiplegia or monoparesis and left eye visual loss
    • -aphasia
  • Symptoms
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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 is based on duration, disability, progression, general medical condition, non-invasive diagnostic testing AND pathology
    • Non-op management: walking program, lifestyle modification, with possible medication.
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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.