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Vascular Surgery - 1 includes:
 

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
      • 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.
    •