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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)

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vascular surgery

Vascular Surgery

Angie Allen, ACNP

Stacey Becker, RN

objectives
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
Who are we? Attendings
  • Dr. Thomas Naslund-Division Chief
  • Dr. Raul Guzman
who are we attendings continued
Who are We?Attendings Continued
  • Dr. Jeff Dattilo
  • Dr. Colleen Brophy
who are we
Who are we?
  • Fellows
  • Dr. Ali Khoobehi
  • Dr. Syed Rizvi
  • Interns:

Carry the consult/resident pager:

831-6374

who are we nurse practitioner
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 we1
Who are we?
  • Case Management

Stacey Becker, RN (Dr. Naslund)

Ann Luther, RN

  • Social Worker

Ann Lacy, RN

other numbers
Other Numbers
  • Vascular Office: 322-2343
  • Vascular Clinic: 936-7485
  • Vascular Lab: 343-9561
arterial disease
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 disease1
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
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
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

symptoms1
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
Cerebral RevascularizationSurgical Intervention

Carotid Endarterectomy

Or

Carotid Artery Stenting

cerebral revascularization post operative care
Cerebral RevascularizationPost 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
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
Cerebral RevascularizationComplications
  • 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
Cerebral VascularizationDischarge 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 vascular disease symptoms
Lower Extremity Vascular DiseaseSymptoms
  • 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).
symptoms continued
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
  • 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
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
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 continued1
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
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
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.