Vascular Surgery - 1 includes:

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Vascular Surgery - 1 includes:

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