Surgical Technology ch 23 peripheral vascular surgery

adventitia

the external covering of an organ or other structure, derived from connective tissue, especially the external covering of a blood vessel.

bifurcation

the act of splitting into two branches

capillary

smallest blood vessel; brings nutrients and oxygen to the tissues and absorbs carbon dioxide and waste products between the blood and tissue fluid in capillary beds

claudication

to limp; pain in a limb (especially the calf) while walking that subsides after rest; it is caused by inadequate blood supply (cramping pain) means to "cramp".

contralateral

pertaining to the opposite side

diastole

relaxation phase of the cardiac cycle

embolus

an abnormal particle (e.g. an air bubble or part of a clot) circulating in the blood

fogarty catheter

catheter, small in diameter and is balloon-tipped, used to facilitate the removal of an embolus

in situ

in the original or natural place or site

innominate

not named or classified

ischemia

decreased supply of oxygenated blood to a body part or organ

intima

innermost layer of a blood vessel, endothelial lining of the vessel along with underlying layer of connective tissue containing variable amounts of elastic fibers.

mitigate

To make less severe

morbidity

illness or disease

mortality

related to death

occlusion

closure or blockage (as of a blood vessel)

papaverine

Vasodilator relaxes smooth muscle in arterial wall stops vasospasm

patency

the state of being open

phrenic

pertaining to the diaphragm

pledget

small square of Teflon sutured over a hole in a vessel, it exerts external pressure over any small needle holes to prevent bleeding and to promote clotting

plethysmography

determining the change in volume of an organ or part; used in the diagnosis of deep vein thrombosis

sinus

dilated channel for venous blood

thrombus

a blood clot formed within a blood vessel and remaining attached to its place of origin

valve

flap of connective tissue between an atrium and a ventricle, or in a vein, that prevents backflow of blood

tunica interma

Inner most layer, Simple Squamous Epithelium

tunica media

middle layer of artery; made up of smooth muscle fibers and thick layer of elastic connective tissue

tunica externa

outermost layer, connective tissue, tough collagen fibers, protects the blood vessels, thickest layer in veins

external carotid artery

the branch of the carotid artery that supplies blood to the face and tongue and external parts of the head

internal carotid artery

the branch of the carotid artery that supplies blood to the brain and eyes and internal parts of the head

vasodilaton

open;increase blood flow brings heat close to the body.

vasoconstrition

is the decrease in the diameter of a vessel

blood pressure

measurement of the force exerted by the heart against the arterial walls when the heart contracts and relaxes

3 factors that affect arterial blood pressure

pumping action of the heart; blood volume; resistance to flow/thickness of the blood

types of emboli

thromboemboli (95%)fat (post femur fx)air (IV cath insertion)amniotic fluid
Ca mets septic emboli (endocarditis)foreign body (additives in IV drugs)

treatment for embolism

enzymatic lysis; anticoagulants Heparin; surgery

fusiform

type of true aneurysms that are circumfenetial: spindle shaped, thick in the middle and tapers at ends

cause of TIA

Embolism

inflammation of a vein

phlebitis

plaque

deposits of cholesterol, calcium, and fat that build up on artery walls and can lead to cardiovascular disease

symptoms of TIA

contralateral hand/arm weakness or sensory loss, face and leg symptoms. Ocularly, can have ipsilateral visual symptoms (amaurosis fugax) or aphasia

intraluminal stent

placed in a vessel after angioplasty to maintain patancy. (palmaz stent) made of stainless steel mesh, titanium, or poly propylene

Arterial blood refers to

blood that is transported AWAY from the heart to the tissues of the body

veins are equipped with

valves that close if blood begins to back up

arterial blood pressure is dependent on

blood volume

Ventricular contraction

Systolic blood pressure is recorded during what?

Stroke volume is correlated with the force of ____________ _____________.

Ventricular contraction

stroke volume

the amount of blood pumped by the left ventricle in each contraction

blood will not circulate

without a pressure gradient between the arterial and venous system

arterial blood pressure is dependent on

blood volume; ventricular contraction; resistance; viscosity/thickness; heart rate

directly affects resistance

viscosity/thickness

central venous pressure (CVP)

Venous blood pressure within the right atrium

aorta

largest artery in the body

right and left coronary arteries

directly supply the myocardium with oxygenated blood

begins at the ascending aorta

Aorta

three major arteries arise from the aortic arch

brachial sephalic; left common carotid; left subclavian

brachial sephalic or innominate artery

supplies the arm and head

bifurcates into the right subclavian and right carotid

brachial sephalic

supplies the right arm

right subclavian

supplies brain and right side of head and neck

right carotid

supplies brain and left side of head and neck

left common carotid

supplies left arm

left subclavian

abdominal aorta

branches to supply the abdominal wall and abdominal viscera

celiac artery

an artery that originates from the abdominal aorta just below the diaphragm and branches into the gastric artery the common hepatic artery and the splenic artery

splenic artery

largest and most obvious branch of the celiac artery, leads to the spleen.

3 main branches of splenic artery

left gastroepiploic; pancreatic; polar

left gastroepiploic artery

supplies lesser curvature of the stomach and esophagus

pancreatic artery

a branch of the splenic artery that supplies the pancreas

polar artery

supplies the spleen

common hepatic artery

artery which runs superiorly and branches off to hepatic artery proper; gastroduodinal; right gastric

hepatic artery proper

Superior to liver; divides into the right and left hepatic arteries supplies the liver and gall bladder

gastroduodinal artery

supplies the stomach, body of pancreas and duodenum

gastric artery

Division of coeliac artery that delivers blood to stomach

super renal artery

supplies the adrenal gland

renal gland

supply the kidneys and a small portion of the adrenal gland

lumbar arteries

supply the spinal cord and its meninges as well as the skin and muscles of the lumbar region of the back

the abdominal aorta bifurcates into the left and right

common iliac arteries at the level of the fourth lumbar vertebra

common iliac arteries

divides inferiorly into 2 main branches right and left: internal iliac and external iliac

right and left iliac arteries become

the femoral arteries as they exit the pelvis and cross the inguinal ligament

upper extremity arterial blood begins at

the aortic arch where the left subclavian artery originates

right subclavian artery branches from

the brachiocephalic artery and becomes the axillary arteries as it enters the axillary region

common carotid bifurcates into

external carotid and internal carotid

external carotid

supplies structures in the neck and head area external to the skull

internal carotid

supply blood to the brain

circle willis

A structure at the base of the brain that is formed by the joining of the carotid and basilar arteries.

the majority of abdominal aortic aneurysms begin

below the renal arteries

arteriovenous (AV) fistula is preferred over an external shunt for long term dialysis because of a decreased chance of

thrombosis

fatty deposits on the walls of arteries are called

atherosclerosis

the rupturing of erythrocytes is called

hemolysis

the self retianing retractor used during femoral popliteal bypass is

weitlaner

a diagnostic test that examines blood flow and metabolic functions of the heart and brain is

positron emission tomography

what procedure is performed for chronic cerebral ischemia

carotid endarterectomy

the movement of blood through a vessel can be assessed by

doppler device

the agent used to flush an artery to prevent clotting is

heparin

a vascular clamp used for occluding peripheral vessels is

bulldog

the instrument commonly used to clamp the aorta during an abdominal aneurysmectomy is

satinsky

the instrument commonly used to remove plaque from the carotid during an endarterectomy is a/an

freer elevator

which synthetic material used for grafts requires preclotting?

Dacron knit polyester

the commonly used suze of suture for peripheral vasculat anastomosis of the popliteal artery is

5-0

the scissors commonly used to extend the arteriotomy during an endarterectomy is a/an

potts-smith

right and left internal jugular vein

drains the brain and the menninges as well as the deep regions of the face and neck

cephalic and basilica veins

drains the superficial tissues of the upper extremeties

basilica vein merges with the

brachial vein just below the head of the humerus to form the axillary vein

intercostals and subcostal veins

drains the muscles of the thoracic wall

inferior vena cava DOES NOT drain the veins of the

spleen, pancreas, gastrointiestinal tract, or gallbladder

hepatic portal vein

drains the spleen, pancreas, gastrointestinal tract, or gallbladder

nutrients from digestion are filtered through the

liver cells

anterior and posterior tibial veins

drains from the deep veins of the foot

lower extremities divide into 2 groups the:

superficial and deep

greatest saphenous vein

longest vein in the body

the primary indicator of occlusive vascular disease

claudication

the 4 p's of complete occlusion of a large normal artery due to an embolism

painful, parasethic, pale, pulseless

arterial embolism may consist of

blood clot, piece of fat, air

major emboli lodge at

bifurcations, origin of large branches, sites of pathologic narrowing

nonoperative therapy for unstable patients

high doses of anticoagulant and enzymatic lysis

arterial embolectomy

balloon tipped fogarty catheter with heparinized saline

arteriosclerosis obliterans

generalized disease affecting the arterial system and involves the fromation of atheroma within the lumen of an artery that restricts blood flow to target tissue

urokinase and streptokinase

types of enzymatic lysis

recommended treatment of aneurysms of the abdominal aorta

resection with synthetic graft placement

balloon dilation of the peripheral artery is an option for patients with

artherosclerotic disease known as percutaneous transluminal angioplasty

most common approach for peripheral vessel angioplasty is through

the ipsilateral femoral artery

may be placed within the vessel after balloon angioplasty to maintain patency of the repair

intraluminal stents

stents may be made of

stainless steel mesh, titanium, polypropylene, other inert materials

two basic reconstructive procedures utilized

bypass grafting and endarterectomy

synthetic grafts made of

knitted polyester, knitted velour (Dacron), Woven polyester (Dacron), polytetraflouroethylene (PTFE)

can be taken across the knee joint without kinking

Polytetraflouroethylene (PTFE)

the only artery in the body that carries unoxygenated blood is the

pulmonary artery

the pacemaker of the heart is the

SA node

which arteries are formed by the bifuracation of the abdominal aorta?

Iliac

the process by which blood cells are formed is known as

hemopoiesis

which of the following arises from the left ventricle

aorta

the pancreas lies behind the sotmach and duodenum in the right and left upper quadrants and is divided into _________protions

three

which organ is responsible for the synthesis of many of the coagulation factors

liver

the atrioventricular (AV) valve between teh left atrium and the left ventricle is the

bicuspid

the inner layer of an artery is known as the

intima

which of the following vessels arises from the right ventricle

pulmonary artery

which of the following vessels do not empty into the right atrium

pulmonary veirns

the large artery found behind the knee is the

popliteal

the large artery that arises from the left side of the aortic arch and descends into the arm is the

subclavian

knitted polyester (Dacron) requires_____________to keep blood from seeping through

preclotting

knitted polyester (Dacron) functions well above the

but may kink across the knee joint

knitted polyester (Dacron) is _______________for rapid tissue growth

porous

intraoperative monitoring uses an Art line in the ___________

radial artery

swan ganz measures

CVP

self retaining retractor of choice for superficial peripheral vascular procedures

Weitlaner

Dietrich coronary set includes____________________
____________________;_____________________;______________________;___________________

vascular dilators;bulldogs;CV forceps;potts coronary scissors;vascualr clamps

are used for most anastomosis

castroviejo needle holder and Debakey forceps

suture boots to tag suture

rubber shods

retract blood vessels

vessel loops or Dacron tape

pledgets

reinforce anastomosis

needles most commonly used for vascular anastomosis

taper needle

femoral guages for peripheral anastomsis

5-0 or 6-0

common carotid guages for peripheral anastomsis

6-0

used for anastomisis and to close arteriotomies

polypropylene (prolene)

intra arterial irrigation

sodium heparin in sodium chloride

for suppression of arterial vasospasm

papverine

hemostatic agents

gelfoan; surgicel. avitene

arteriotomy

used for multiple peripheral vascular procedures

heperanize patient;clamp proximal;clamp distal;incise vessel with #11 blade on # 7 handle;extended with angeled______________

arteriotomy; potts scissors

____________ procedure preps from_________ and down to and including the _____________

aortofemoral bypass; axillary; feet

should be readily available for the patient

blood

to moisten surgeons hand before he ties prolene suture

saline

aortofemoral bypass incision

anterior abdominal and incisions over bilateral groin

prep for femoropopliteal bypass

mid abdominal to toes with leg prepped circumfencially

common femoral artery is clamped with ______________ angled vascular clamp in teh femoropopliteal bypass

DeBakey

a__________________ __________________is placed between the two femoral arteries for patients with unilateral iliac arterial occlusion

subcutaneous graft

primary indication for carotid endarterectomy

transient cerebral ischemia

TIA or transient ischemic attacks

forerunners to a permanent stroke

allows blood flow to the brain while the carotid is clamped

javid shunt

common carotid suture

6-0

vascualr clamps are removed from the______________,____________ and ___________ carotid arteries in that order

common; external; internal

vascular clamps are applied first to the __________________then to the ____________ and lastly to the _____________________ in that order

internal carotid; external carotid; common carotid

Tunica

the wall of an artery consists of three layers called...

Arterial blood is pumped by the heart through a large system of blood vessels called ...

Arteries

Arterial blood refers to...

blood that is transported "away" from the heart to the tissues of the body.

Capillaries

microscopic vessels designed to exchange nutriends and wastes between the blood and tissue fluid around the cells (capillary beds).

Capillaries unite to form...

venules. (smallest of veins.

Venules unite to form...

progressively larger blood vessels called veins, which eventually become the superior and inferior vena cava, largest of veins.

Largest veins are...

superior and inferior vena cava

Blood Pressure is the force that blood exerts against the...

internal walls of bood vessels.

Venous blood pressure is..

lower than arterial pressure.

Venous blood pressure within the right atrium is referred to as...

Central venous pressure (CVP)

The coronary arteries directly supply the...

myocardium with oxygenated blood.

Three major arteries emerge from the aortic arch:

brachiocephalic artery (a.k.a. innominate artery, the left common carotid arter, and the left subclavian artery.

brachiocephalic artery supplies...

the blood to the tissues of the arm and head, the 1st branch of aortic arch, veering to the right.

Which is the unpaired vessel arising anteriorly from the abdominal aorta, just above the bifurcation of the aorta?

Inferior mesenteric artery.

Common carotid artery ..

bifurcates into the internal and external carotid arteries at the superior border of the larynx.

External carotid artery supplies..

structures in the neck and head area external to the skull. Main branches include superior thyroid artery (serves the hyoid muscles, larynx, vocal cords, & thyroid gland) ascending phryngeal artery, lingual artery (which supplies the tongue & sublingual s

Internal carotid artery and vertebral arteries supply...

blood to the brain. It enters the base of the skull through carotid canal of the temporal bone.

Arterial Embolism -

sudden loss of circulation to an extremity. Addition to blood clots, it may consist of fat, air, or even portions of tumor that circulate through cardiovascular system until lodged in smaller vessels, blocking blood flow to extremity or organ.

Diagnostic procedures & tests for evaluation of peripheral vascular disease include:

plethysmography (diffuse sm. vessel arterial disease), DOPPLER Probe (measurement of blood flow to particular artery), Computer Axial Tomography (magnetic resonance imaging, & ultrasonography for detection of & evaluation of carotid artery atherosclerosis

Non operative therapy is the best option for...

unstable patients of arterial embolisms. (HEPARIN-anticoagulant/blood thinner) allows patient's own fibrinolytic system to lyse the occluding clot.

Surgical intervention for the removal of emboli (arterial embolectomy) involves an incision (#11 blade to punction vein with) made into the affected artery for removal of thromboembolitic material and restoration of flow to the extremity.

Arteriotomy - facilitates the removal of the embolus and the insertion of a ballon-tipped fogarty (embolectomy)catheter is done.

Aneurysms of the Abdominal Aorta

Triple AAA - asymptomatic patients are diagnosed. they are generally fusiform. majority arise below the origin of the renal arteries & terminate at the bifurcation of the aorta or common iliac arteries.

Peripheral Vessel Angioplasty

baloon dilation of the peripheral artery (percuaneous transluminal angioplasty) for patients who are symptomatic atherosclerotic disease.

Procedural steps for Peripheral artery angioplasty...

1.-femoral artery is punctured w/ arterial needle/cannula assembly & needle/obturator is removed.
2. - guidewire introduced through cannula into femoral artery.
3. - ballon-tipped angioplasty catheter is threaded over guidwire & positioned across peripher

Drugs handled by STSR during peripheral vascular procedure include:...

*
Papaverine-for the suppression of arterial vasospasm.
**
**sodium heparin in sodium chloride for intra-arterial irrigation.
**lidocaine-with or w/o epinepherine for local procedures or post. op anesthetic.
**antibiotic of surgeon's choice in sodium chlo

Counteraction for heparine or Antagonist (reverses) is

Prodimine sulfate.

Aortofemoral Bypass

Arterial obstructions due to atherosclerosis occurs most frequently in the aortoiliac segment of the arterial system.

Procedures Aortofemoral bypass (important highlights)

Supplies: heparin, antibiotic irrigation, contrast solution.Vessel loops and/or umbilical tape, Gelfoam, Fogarty clamp inserts. Practical considerations: surgeon's hands should be moistened w/saline from an Asepto before tying Prolene Sutures, patient hep

Procedures Aortofemoral bypass (important highlights

If aorta is friable, Teflon=coated Pledgets may be used with suture to reinforce the anastomosis. this prevents tears in tissue vessels during suturing.

To presoak a graft?

soak it in patient's blood.

Abodominal Aortic Aneurysmectomy

Aneurysms are weakened areas in an arterial wall. an aortic aneurysms are a threat to life due to the size of the vessel. an elective alternative is to resect-aneurysmectomy.

Aorta-

largest Artery

Abdominal Aortic Aneurysmectomy Procedure

Supplies: Suture is 4-0, 5-0, 6-0 Prolene, 2-0, 3-0 silk ties, 18-32in. 2-0, 3-0 silk stick ties. Vessel loops and/or umbilical tape (used to retract blood vessels - leave in saline because it is handed wet to surgeon., General anesthesia, Supine Position

In Abdominal Aortic Aneurysmectomy Procedures...

Only certain amount of blood can be squeezed out of lap sponges to reuse in cell saver. However, no heparine can be present in reused blood.

In Abdominal Aortic Aneurysmectomy Procedures

an aortic vascular clamp is carefully applied to the aorta above the aneurysm.

Femoropopliteal Bypass-

the material of choice remained the autogenous saphenous vein, eventhough obstruction is in distal portion of the femoral artery can be adequately bypassed with synthetic graft material. Valvutone is used to take care of valves.
General anesthesia, affect

Femoropopliteal Bypass Procedure

General Anesthesia, Prep: midabdomen to toes is prepped w/ leg prepped circumferentially. surgeon's hands moistened w/saline from asepto before tying prolene sutures, 1st incision made over distal portion of popliteal artery, extending from post. border o

When Arteriotomy performed...

anterolateral portion of common femoral artery, & saphenous vein is anastomosed in an end to side fashion w/ continuous 6-0 Prolene suture.

Arteriotomy set up... to open up Arteries:

Mayo Stand-
1. #11 Blade
2. Pot Scissors
3. Pick Up's (Gerard's) for fine vascular procedures
4. Free elevator

Carotid Endarterectomy-

Main indication for carotid endarterectomy is transient cerebral ischemia. small pieces of plaque break away from common carotid or internal coratid artery and are flushed upstream to lodge in small cerebral vessels, temporarily blocking blood flow to tha

Carotid Endarterectomy- procedures

Positioning - supine w/head turned approximately 45 degrees to the unaffected side. General or regional cervical bloc.

Carotid Endarterectomy- procedures Pearl of Wisdom:

Typical sequence in all endarterectomies after vessel exposure is achieved: Pattern as follows in peripheral vascular surgery.
1. vessel is dissected free from surrounding tissues.
2. right angle clamp placed underneath vessel & opened.
3. *
vessel loops