ANESTHESIA For VASCULAR SURGERY Mark Welliver MS, CRNA

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ANESTHESIA For VASCULAR SURGERY Mark Welliver MS, CRNA

  1. 1. ANESTHESIA For VASCULAR SURGERY Mark Welliver MS, CRNA Significant contributions from original by Gwenn Randal MSN, CRNA
  2. 2. Outline • Introduction • Carotid endarterectomy (not covered) • Peripheral vascular surgery – Bypass grafting – Embolectomy • Abdominal aortic surgery • Endovascular Surgery • Thoracic aortic surgery
  3. 3. Vascular Surgery Patients • Coexisting diseases: – CAD 40-80% – Htn – Diabetes – Smokers – CNS; carotid disease, stroke – Renal • 50% of post op mortalities d/t MI • If the surgical site is sclerotic so are other areas
  4. 4. Carotid Vascular surgery • Consider carotid vascular disease coexisting • CEA Covered next spring in trauma course
  5. 5. Peripheral Vascular Surgery • Bypass grafting for occlusive disease or aneurysms • Upper or lower extremities • Endogenous vessels or synthetic (Gortex) • Anesthesia options: – General – Regional
  6. 6. Peripheral Bypass – Potential for blood loss; type and cross 2U – 2 large bore IV access (#18 minimal) – Consider central line; fluids and CVP (PA?) – Fluid warmers with blood tubing – Colloids available; Hespan, albumin – A-line for unstable or ASA 3,4 – Heating blankets (burn risk) – Serial H&H, Abgs
  7. 7. Peripheral Bypass • Femoral-popliteal and lower; – general, spinal, epidural • Ileo-femoral and lower; – general, spinal, epidural • Axillo-femoral; – General, regional, local
  8. 8. Peripheral Embolectomy • Potential for significant blood loss • Type and screen minimal • Large bore IV access • Often MAC with local • Duration?
  9. 9. Abdominal Aortic Surgery • Aorta below diaphragm • Bypass grafting for occlusive disease or aneurysms • Over sew or synthetic grafts (Gortex) • Anesthesia option; General alone or with epidural catheter adjunct
  10. 10. Abdominal Aortic Aneurysm  Common in older adults >60 (5-7%)  Appears to be a genetic link because this type of aneurysm tends to run in families.  Usually occurs in people with atherosclerosis.  Symptoms: abdominal, groin, back pain, syncope, flank mass, or paralysis  Diagnosis: routine physical find, abdominal ultrasound.
  11. 11. Abdominal Aortic Aneurysm Society of Vascular Surgery and the International Society for Cardiovascular Surgery have characterized abdominal aneurysms as: -suprarenal -juxtarenal -pararenal -infrarenal 90-95% of AAAs involve the infrarenal abdominal aorta.
  12. 12. True aneurysm Involves dilation of all 3 layers of the vessel wall: (outer) Tunica externa- fibrous connective tissue (middle) Tunica Media- smooth muscle/elastic tissue (inner) Tunica interna- epithelial layer, squamous cells False aneurysm Caused by disruption of 1 or more layers of the vessel wall. Aneurysms
  13. 13. Abdominal Aortic Aneurysm <4cm--- u/s q 6 months 4-5cm– elective repair w/low operative risk and good life expectancy. 5-6 cm– need repair (mortality rate 0.9- 5%) 6-7 cm– threshold for rupture (mortality as high as 75%).
  14. 14. Overview  Large incision in the abdominal wall, just below your breastbone to top of the pubic bone  Aorta clamped  Aneurysm cut open  Plaque and clotted blood removed  Aortic graft sewn in place- functions as a conduit for blood flow
  15. 15. Management – Potential for blood loss; type and cross 2U – large bore IV access (#18 minimal) – Central line; fluids and CVP (PA?) – Fluid warmers with blood tubing – Colloids available; Hespan, albumin – A-line – Vasodilator gtts and vasopressors – Clamping issues… – Heating blankets (burn risk) – Serial H&H, ABGs
  16. 16. Endosvascular Surgery  Performed under local, mac, ga, regional  Radial a-line & IV’s in right arm  Left arm & both groins used for surgical access  Patients are discharged in 1-2 days post-op  Approved September 2000 by FDA.  Disadvantages:  Endoleaks- (failure to exclude the AAA)  Require follow-up eval’s w/serial CT scans  Demands more office visits than open
  17. 17. Endovascular grafting (EVR)  Catheter tip inserted through a groin artery into abdominal aorta using fluoroscopy  Catheter’s tip holds a deflated balloon.  Balloon inflated, graft opens to span the length and width of the artery.  Devices at both ends of the graft secure it to the inner wall of aorta to strengthen it and keep from rupturing  May not be available at all hospital facilities.  ADV: much less invasive
  18. 18. Endovascular Stent Grafts Indications Severe COPD Severe cardiac disease Active infection Medical problems that preclude operative intervention. 1.5cm neck of aorta to pass graft between the renal arteries and the aneurysm Anatomy/ braches/graft selection factors
  19. 19. Thoracic Aortic Surgery • Aneurysms • Dissection • Occlusive disease • Trauma (covered in neuro/trauma) • Coarctation (covered in Pediatrics)
  20. 20. Risks • Most often requires CPB • Large blood losses • Hypertension pre-op, hypotension intra-op • Myocardial ischemia • Renal ischemia • Spinal ischemia • Death
  21. 21. Aneurysms • Rupture-death #1 risk. >6cm 50% rupture w/in one year. • Surgical repair 2-5% mortality risk • Leaking = >50% mortality • Thoracic aneurysms: tracheal &/or bronchial compression/deviation, Laryngeal nerve compression
  22. 22. Thoracic Aneurysm • Ascending-between aortic valve & innominate • Arch- between innominate & l. subclavian • Descending- distal to l. subclavian
  23. 23. Classification of thoracic aneurysms
  24. 24. Anesthetic Management • Ascending Aorta: • Similar to cardiac surgery utilizing CPB – Consider fem-fem bypass(risk rupture w/sternotomy • Special considerations: – Long aortic cross clamp times – Large blood loss – Right radial A-line (why?)
  25. 25. Anesthetic Management • Aortic Arch: • Similar to cardiac surgery utilizing CPB median sternotomy • Goal- cerebral protection – Hypothermia – Thiopental infusion – Maintain flat EEG – Corticosteroids – Free radical scavengers
  26. 26. Anesthetic Management • Descending Aorta: • Usually without CPB • L. thoracotomy incision • One lung anesthesia • PA cath, A-line, Many large bore ivs, TEE, Cell saver, SSEP • Cross Clamping issues: – ↑SVR, myocardial ischemia, CHF, ↓CO, – Limit fluids pre-clamping – ↑anesthetic depth – Ntg, nitroprusside gtts primed & ready • Clamp Release issues: – SEVERE HYPOTENSION,↓SVR – Preload w/fluids(crystaloid,colloid) before release, vasodilators OFF – ABGs acidosis (bicarb, ↑min. vent.) – Paraplegia risk d/t thoracolumbar artery injury – Renal failure
  27. 27. Aortic Occlusive Disease • Incorporates Aortobifem grafting with/without peripheral thromboendarterectomy • Tx; same as above with focus on location • Rarely a localized phenomena

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