Vascular

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AAA

Procedure: AAA (EVAR & Open)

Indication: Aneurysm usually with a diameter larger than 5.5cm

Description: Patient is anesthetized and vascular access is gained (femoral arteries). The process then involves guidewires, imaging, balloons, stents, and final images. The process must be able to be converted to an open procedure emergently if required. If performed open, a midline abdominal incision is performed allowing access to the aneurysm.

Post-op Implications:

Complications: Endoleak: Incompetence of device, requires CT imaging.

Femoral access:

  • Bleeding requires direct pressure. Acute thrombosis of the accessed vessel, distal embolization, dissection, pseudoaneurysm, and arteriovenous fistula.
  • Distal limb ischemia: Caused by embolization, thrombus, or device malfunction. Depending on location of aneurysm, blood flow can be impaired to kidneys, intestines, and distal extremities.
  • Contrast induced nephropathy: keep IVF until tolerating PO. Meds: Pain is managed with NSAIDS and opioids (Possibly PCA) as needed. Restart home meds as soon as tolerating PO. If open repair, may have an epidural.

Principles: Lay flat for 6hrs post-op to protect graft site and femoral access sites. Frequent distal pulse checks and groin checks per protocol. Care Plan: Lay flat for 6hrs post-op. Frequent distal pulse and groin checks. Pulmonary toileting, wound care/assessment, foley hygiene, manage IVF, monitor and control pain, NPO for first 6hrs.

Course of Care: POD #1 Ambulate, D/C foley, restart home Rx if tolerating PO, CL diet or regular diet if tolerating PO, possibly D/C to floor.

Room Setup: Humidified 02, oral suction, standard IV pump setup, possibly PCA setup, SCDs.

CEA

Procedure: Carotid Endarterectomy (CEA)

Indication: Carotid atherosclerotic disease (asymptomatic or symptomatic), carotid stenosis.

Description: Can be general anesthesia or local. Incision is made in neck to access the Internal Carotid Artery (ICA), the ICA is dissected and plaque is removed from the internal lumen. The artery may have a primary repair or a patch. The skin is most often closed with derma-bond.

Post-op Implications:

Complications:

  • HTN: labetalol, esmolol, nitro, or nitroprusside.
  • Hypotension: phenylephrine.
  • Headache: needs CT scan, possible hyperperfusion syndrome.
  • Hematoma: Can cause loss of airway, possibly go back to OR.
  • Neuro: Frequent neuro checks due to risk of neurological insult or nerve injury.

Meds: Start home meds as soon as possible. Pain is usually not severe.

Principles: Disturbed baroreceptor in CA can cause labile BP and HR, SBP goal 100-150mmHg. Disrupted cerebral blood flow can cause stroke.

Care Plan: Pulmonary toilet, skin care, pain management, manage IVF, and wound care. NPO ->home diet POD#1. Possible foley overnight. AM labs. BP control (A-line care if applicable).

Course of Care: Usually discharge or transfer the next day if stable overnight.

Room Setup: Possible A-line set-up. Standard IV pump, suction, 02 mask ->NC. SCDs.

Bypass

Procedure: Aorto-femoral bypass/stent. Fem-pop bypass/stent/endarterectomy, femofemoral bypass.

Indication: Claudication, limb ischemia, non-healing ulcers.

Description: (Fem-pop): Femoral access is gained. Saphenous vein is harvested or a prosthetic is used and the occluded portion of artery is bypassed. Bypass can occur above the knee, below, or through the joint area as well. Femoral access is then closed. Stent and endarterectomy procedures are generally the same except instead of bypass, a stent is placed or endarterectomy is performed at the location of the occlusion.

Post-op Implications:

Complications:

  • Bleeding: Usually seen at femoral access sites, apply firm downward pressure on femoral artery for 15minutes. Check ptt lab values.
  • Graft thrombosis/distal emboli: Keep legs straight and monitor pulses per protocol.
  • Graft infection: Usually necessitates removal of graft.
  • Compartment syndrome: swelling around fascial compartments the of leg, seen as intense pain and tense swollen leg.

Meds: PCA for pain, oxycodone once tolerating PO. ASA and/or warfarin therapy to reduce thrombosis.

Principles: lay flat for 6hrs post-op to decrease disturbance of surgical sites and graft. Keep lower extremities warm to promote blood flow. Avoid bending of legs even after 6hrs initial post-op time period is up, no crossing of legs.

Care Plan: Lay flat for 6hrs post-op. Frequent distal pulse and groin checks(Q15,Q30,QH). Pulmonary toileting, wound care/assessment, foley hygiene, manage IVF, monitor and control pain, NPO for first 6hrs.

Course of Care: Extubated in OR. Lay flat for first 6hrs, avoid bending of legs and hips for several days. OOB after 6hrs. Resume diet after 6hrs. D/C foley after ambulating. Post-op ABI’s.

Room Setup: Humidified 02, oral suction, standard IV pump setup, possibly PCA setup, SCDs.