Vascular SurgeryVascular Surgery

Angie Allen, ACNPAngie Allen, ACNP

Stacey Becker, RN Stacey Becker, RN

ObjectivesObjectives

1.1. Identify our team.Identify our team.2.2. Peripheral Artery DiseasePeripheral Artery Disease3.3. Cerebral RevascularizationCerebral Revascularization4.4. Lower Extremity RevascularizationLower Extremity Revascularization5.5. Lower Extremity AmputationLower Extremity Amputation6.6. Abdominal Aortic Aneurysms (endovascular)Abdominal Aortic Aneurysms (endovascular)7.7. Thoracic Aortic Aneurysms (endovascular)Thoracic Aortic Aneurysms (endovascular)8.8. Abdominal Aortic Aneurysms (open)Abdominal Aortic Aneurysms (open)9.9. Thoracic Outlet Thoracic Outlet

Who are we? Who are we? AttendingsAttendings

Dr. Thomas Naslund-Dr. Thomas Naslund-Division ChiefDivision Chief

Dr. Raul GuzmanDr. Raul Guzman

Who are We?Who are We?Attendings ContinuedAttendings Continued

Dr. Jeff DattiloDr. Jeff Dattilo

Dr. Colleen BrophyDr. Colleen Brophy

Who are we?Who are we?

FellowsFellows Dr. Ali KhoobehiDr. Ali Khoobehi Dr. Syed RizviDr. Syed Rizvi Interns: Interns:

Carry the consult/resident pager: Carry the consult/resident pager:

831-6374831-6374

Who are we?Who are we?Nurse PractitionerNurse Practitioner

Angie Allen, ACNP-BCAngie Allen, ACNP-BC

First Call for Vascular First Call for Vascular

M-F 0730-1600M-F 0730-1600

886-0163 (cell)886-0163 (cell)

835-8202 (pager)835-8202 (pager)

Who are we?Who are we?

Case ManagementCase Management

Stacey Becker, RN (Dr. Naslund)Stacey Becker, RN (Dr. Naslund)

Ann Luther, RN Ann Luther, RN

Social WorkerSocial Worker

Ann Lacy, RNAnn Lacy, RN

Other Numbers Other Numbers

Vascular Office: 322-2343Vascular Office: 322-2343 Vascular Clinic: 936-7485Vascular Clinic: 936-7485 Vascular Lab: 343-9561Vascular Lab: 343-9561

Arterial DiseaseArterial Disease

Peripheral Artery Disease (PAD): leading case of death Peripheral Artery Disease (PAD): leading case of death worldwide. Polyvascular disease. worldwide. Polyvascular disease.

Atherosclerosis: Most likely the cause of PAD. Hardening Atherosclerosis: Most likely the cause of PAD. Hardening of the artery or loss of elasticity. of the artery or loss of elasticity.

Arterial Pathophysiology:Arterial Pathophysiology:

1. Occlusive disease: Atherosclerosis is symptomatic by 1. Occlusive disease: Atherosclerosis is symptomatic by gradually occluding the artery to the target organ or gradually occluding the artery to the target organ or extremity. (kidneys, colon, legs, or arms)extremity. (kidneys, colon, legs, or arms)

2. Symptoms occur with critical arterial stenosis (75 % of 2. Symptoms occur with critical arterial stenosis (75 % of cross sectional of lumen is obliterated)cross sectional of lumen is obliterated)

Arterial DiseaseArterial Disease

Aneurysmal Disease: occurs due to loss of Aneurysmal Disease: occurs due to loss of structural integrity of vessel wall. Over time structural integrity of vessel wall. Over time this will result in dilation and aneurysm this will result in dilation and aneurysm formation. formation.

Cerebral RevascularizationCerebral Revascularization

Symptomatic: Patients who have carotid Symptomatic: Patients who have carotid stenosis or occlusion that have exhibited a stenosis or occlusion that have exhibited a CVA or TIACVA or TIA

Asymptomatic: Patients who have carotid Asymptomatic: Patients who have carotid stenosis or occlusion that are high risk for stenosis or occlusion that are high risk for CVA (i.e. hypertension, hyperlipidemia, CVA (i.e. hypertension, hyperlipidemia, smoker, obesity, CAD, etc.)smoker, obesity, CAD, etc.)

SymptomsSymptoms

Right sided symptoms: Right sided symptoms:

-Left hemiplegia or monoparesis and right eye -Left hemiplegia or monoparesis and right eye visual lossvisual loss

Left sided symptoms:Left sided symptoms:

-Right hemiplegia or monoparesis and left -Right hemiplegia or monoparesis and left eye visual losseye visual loss

-aphasia-aphasia

SymptomsSymptoms

Visual symptoms are due to ischemia of the Visual symptoms are due to ischemia of the retina.retina.

Amaurosis fugaxAmaurosis fugax

-Transient visual loss-Transient visual loss

-”Window shade”, “flashing lights”, or -”Window shade”, “flashing lights”, or “sparks”“sparks”

Cerebral RevascularizationCerebral RevascularizationSurgical InterventionSurgical Intervention

Carotid EndarterectomyCarotid Endarterectomy

Or Or

Carotid Artery StentingCarotid Artery Stenting

Carotid EndarterectomyCarotid Endarterectomy

Carotid Artery StentingCarotid Artery Stenting

Cerebral RevascularizationCerebral RevascularizationPost Operative CarePost Operative Care

Neuro Assessment: VERY IMPORTANT. Essential Neuro Assessment: VERY IMPORTANT. Essential for recognizing neurological deficits.for recognizing neurological deficits.

Contralateral hemiparesis: technical problem with Contralateral hemiparesis: technical problem with endarterectomy with immediate return to OR. Notify endarterectomy with immediate return to OR. Notify team ASAP. Arterial duplex may be ordered.team ASAP. Arterial duplex may be ordered.

Defuse neurological deficit: possible internal capsule Defuse neurological deficit: possible internal capsule stroke secondary to hypotensive episode. stroke secondary to hypotensive episode.

Delayed neurological deficit: 12-24 hours Delayed neurological deficit: 12-24 hours postoperatively. Arterial Duplex with possible CTA postoperatively. Arterial Duplex with possible CTA of head and neck for evaluation of brain hemorrhage of head and neck for evaluation of brain hemorrhage or CVA and evaluation of carotid. or CVA and evaluation of carotid.

Post Operative Care Post Operative Care ContinuedContinued

Dextran 40: instituted for antiplatelet purposes and Dextran 40: instituted for antiplatelet purposes and may be continued for 24 hours postoperatively. may be continued for 24 hours postoperatively.

NPO until POD 1 for possible exploration. NPO until POD 1 for possible exploration. D5 ½ NS while patient is NPOD5 ½ NS while patient is NPO POD 1: Initiation of Plavix 75 mg subcutaneous daily POD 1: Initiation of Plavix 75 mg subcutaneous daily

(if no concerns for hematoma)(if no concerns for hematoma) Incision: Leave dressing dry and intact until POD 1, Incision: Leave dressing dry and intact until POD 1,

may remove. Incision will be closed with disolvable may remove. Incision will be closed with disolvable sutures, leave open to air unless draining.sutures, leave open to air unless draining.

Cerebral RevascularizationCerebral RevascularizationComplicationsComplications

Hypertension: 20 % of patients. SBP 100-140Hypertension: 20 % of patients. SBP 100-140 Neck Hematoma: May compromise breathing and Neck Hematoma: May compromise breathing and

swallowing. swallowing. -May require immediate surgical intervention for evacuation-May require immediate surgical intervention for evacuation -Order tracheostomy kit Stat to the bedside -Order tracheostomy kit Stat to the bedside Local Nerve Injuries: Most common laryngeal and Local Nerve Injuries: Most common laryngeal and

hypoglossal nerves presenting as temporary weakness in hypoglossal nerves presenting as temporary weakness in speech, swallowing, tongue or lip movement. Less than 0.5% speech, swallowing, tongue or lip movement. Less than 0.5% result in permanent damage. result in permanent damage.

Hyperperfusion Syndrome: 1-2 % occur 3-7 days post Hyperperfusion Syndrome: 1-2 % occur 3-7 days post operatively. Headache, Seizures, and Intracranial operatively. Headache, Seizures, and Intracranial Hemorrhage. Hypertension may accompany. Supportive Hemorrhage. Hypertension may accompany. Supportive managementmanagement

Cerebral VascularizationCerebral VascularizationDischarge InstructionsDischarge Instructions

Incision Care: Leave open to air, unless draining. Wash with Incision Care: Leave open to air, unless draining. Wash with antibacterial soap and water and use white wash cloths.antibacterial soap and water and use white wash cloths.

Immediately call 911 with patient has headache with Immediately call 911 with patient has headache with associated decreased level of consciousness or seizure associated decreased level of consciousness or seizure activities.activities.

Follow up in Vascular Clinic 4 weeks postoperatively.Follow up in Vascular Clinic 4 weeks postoperatively. Discharge Medications: Plavix and pain medicationDischarge Medications: Plavix and pain medication Plavix injection education.Plavix injection education. Activity: Do not resume normal work activities until follow Activity: Do not resume normal work activities until follow

up apt. No driving until that time, do not return to work. up apt. No driving until that time, do not return to work. (?????)(?????)

Lower Extremity RevascularizationLower Extremity RevascularizationAnatomyAnatomy

Lower Extremity Vascular DiseaseLower Extremity Vascular DiseaseSymptomsSymptoms

Claudication: pain at rest, present with ambulation. Claudication: pain at rest, present with ambulation. Typically seen one level below the disease. Typically seen one level below the disease.

Critical Ischemia: Rest pain may be first symptoms Critical Ischemia: Rest pain may be first symptoms of severe ischemia. Sharp, localized pain to forefoot of severe ischemia. Sharp, localized pain to forefoot to below the ankle, dependent rubor and pallor with to below the ankle, dependent rubor and pallor with elevation. 95% loose limb in 1 yr without elevation. 95% loose limb in 1 yr without revascularization. revascularization.

Critical Ischemia: Non healing ulcers. (arterial vs Critical Ischemia: Non healing ulcers. (arterial vs venous)venous)

Critical Ischemia-Gangrene: Skin and subcutaneous Critical Ischemia-Gangrene: Skin and subcutaneous tissue involvement. Dry (noninfected black eschar) tissue involvement. Dry (noninfected black eschar) vs Wet (macerated, purulent drainage). vs Wet (macerated, purulent drainage).

Gangrene-DryGangrene-Dry

Symptoms ContinuedSymptoms Continued

Microemboli: Blue Toe Syndrome causes Microemboli: Blue Toe Syndrome causes blue, mottled spots over the toes. May be blue, mottled spots over the toes. May be painful. painful.

Acute Arterial Ischemia: Sudden onset of Acute Arterial Ischemia: Sudden onset of extremity pain, pallor, paresthesia, extremity pain, pallor, paresthesia, pulselessness, and poikilothermia. Caused by pulselessness, and poikilothermia. Caused by stenotic artery or emboli if no previous stenotic artery or emboli if no previous vascular disease. vascular disease.

TREATMENTTREATMENT Treatment is based on duration, disability, Treatment is based on duration, disability,

progression, general medical condition, non-invasive progression, general medical condition, non-invasive diagnostic testing AND pathologydiagnostic testing AND pathology

Non-op management: walking program, lifestyle Non-op management: walking program, lifestyle modification, with possible medication.modification, with possible medication.

Diagnostic Testing: Arterial duplex with segmental Diagnostic Testing: Arterial duplex with segmental pressures/ABI’s (vascular lab), CTA or MRA, pressures/ABI’s (vascular lab), CTA or MRA, arteriogram, plain films, ECG (if ischemic toes-could arteriogram, plain films, ECG (if ischemic toes-could be from a-fib), PT /PTT/INR/Platelet workup.be from a-fib), PT /PTT/INR/Platelet workup.

Operative ManagmentOperative Managment

Percutaneous transluminal angioplasty/stentingPercutaneous transluminal angioplasty/stenting Femoropopliteal or Pop-DP, etc. bypass Femoropopliteal or Pop-DP, etc. bypass

(saphenous vein, Dakron, ePTFE)(saphenous vein, Dakron, ePTFE) Femoropopliteal percutaneous endovascular Femoropopliteal percutaneous endovascular

interventionintervention Aortoiliac or Aortobifemoral bypass or Aortoiliac or Aortobifemoral bypass or

angioplasty with or without stentingangioplasty with or without stenting ThromboembolectomyThromboembolectomy AmputationAmputation

Post-Operative CarePost-Operative Care

ICU stabilization after aortic operations ICU stabilization after aortic operations (stability of vitals/hemodynamics, respiratory, (stability of vitals/hemodynamics, respiratory, fluid, electrolyte, cardiac, laboratory -pcv, fluid, electrolyte, cardiac, laboratory -pcv, blood glucose, lytes, coags- management).blood glucose, lytes, coags- management).

Fluids: D51/2 NS 20 KCL at 75 mL/hrFluids: D51/2 NS 20 KCL at 75 mL/hr Rewarm and vasodilate: bolus may be Rewarm and vasodilate: bolus may be warrantedwarranted Post op day 3-4: mobilization of fluids-may Post op day 3-4: mobilization of fluids-may

see lasix given. see lasix given.

Post-Operative Care ContinuedPost-Operative Care Continued Pain Control: essential for mobilization. PCA or Pain Control: essential for mobilization. PCA or

percocet or lortabpercocet or lortab Ambulation: PT/OT consult, POD 1Ambulation: PT/OT consult, POD 1 Rooke Perioperative BootsRooke Perioperative Boots Antibiotics: continued for 24 hoursAntibiotics: continued for 24 hours Wound Care: remove dressing POD 1, may leave Wound Care: remove dressing POD 1, may leave

open to air unless draining. Wash with antibacterial open to air unless draining. Wash with antibacterial soap and water and use white wash cloths. soap and water and use white wash cloths.

Amputation Wounds: Takedown is on POD 2, will Amputation Wounds: Takedown is on POD 2, will require knee immobilizer.require knee immobilizer.

High Risk for Pressure UlcersHigh Risk for Pressure Ulcers

ComplicationsComplications Hemorrhage from graft: Exploration required. Hemorrhage from graft: Exploration required. Thrombis (graft occlusion) PULSES< PULSES<PULSESThrombis (graft occlusion) PULSES< PULSES<PULSES InfectionInfection Stage 1: Involving skin and dermis-wound care, Stage 1: Involving skin and dermis-wound care,

antibiotics.antibiotics. Stage 2: Extending to subcutaneous and fatty tissue but Stage 2: Extending to subcutaneous and fatty tissue but

not graft-Exploration and washout in the OR, continued not graft-Exploration and washout in the OR, continued wound care and antibiotics. wound care and antibiotics.

Stage 3: Graft involvement-Exploration and washout in Stage 3: Graft involvement-Exploration and washout in the OR with graft removal with establishment of new route of the OR with graft removal with establishment of new route of perfusion. Continued wound care and 6 weeks of IV perfusion. Continued wound care and 6 weeks of IV antibiotics.antibiotics.

Complications ContinuedComplications Continued

Compartment Syndrome: Caused by Compartment Syndrome: Caused by prolonged ischemia (> 6 hrs) then prolonged ischemia (> 6 hrs) then revascularization resulting in edema in the calf revascularization resulting in edema in the calf muscles. Leg pain with sensory deficits to the muscles. Leg pain with sensory deficits to the dorsum of the foot and weakness of toe dorsum of the foot and weakness of toe dorsiflexion. Measure Compartment Pressure. dorsiflexion. Measure Compartment Pressure. Treatment: fasciotomy. Treatment: fasciotomy.